Tricks of the Trade

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Tricks of the Trade

• Difficult to Abstract Variables
• Tips from the CDACs

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CDACs

• Slides are adapted from slides done by Mary
  Samuelson
• Paulette Parquette
• Training Coordinators at the CDAC with their
  permission
• Jan 01/05 discharges

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Pneumonia

• Working Diagnosis on Admission

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Working Diagnosis

• For working diagnosis, pneumonia need not be the
  primary or only diagnosis, but may only be
  mentioned as suspected, rule out etc, at ANY time
  from arrival through admission.
• The phrases doubt pneumonia and ruled out
  pneumoniaare NOT acceptable for working
  diagnosis.
• Differential Diagnosis is acceptable.

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Working Diagnosis ED Admits

• Use only ED physician documentation.
• This includes ANY Physician/PA/NP who sees the
  patient in the ED.
• Consults done in the ED are acceptable.
• Pneumonia found on admission documents (i.e.
  history and physical, admit note etc.) that are
  timed/dictated prior to the time of admission
  are also acceptable.

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Working Diagnosis ED Admits

• Was the MD who writes the diagnosis of pneumonia
  actually in the ED to see the patient prior to
  the time of admission (i.e consulting MD called
  into the ED to evaluate)?
• Was the the time found on the admission document
  (HP, consult or admit note) prior to or at the
  time of admission?

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Working Diagnosis ED Admits

• Acceptable Sources
• HP
• Admission order
• Admission note
• Consults done before the time of admission
• ED records

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Time of Admission

• Defined as the point at which the decision is
  documented to admit the patient.
• When looking to compare a time from an
• admission document like a consult or HP use
  the time found on the admit order as the Time of
  Admission.
• If the time on the document with pneumonia is
  prior to or the same as the Time of Admission
  from the admit order then the working diagnosis
  is YES

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ED Admits to Observation

• If the patient is admitted from the ED to
  Observation and later admitted to inpatient ALL
  admission documents must apply to the observation
  admission.
• Diagnosis of pneumonia must be present on the
  initial admission to Observation.

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Time of Admission Examples

• No Dx found on the ED record but a consult
  dictated at 1330 has pneumonia as impression.
• Admit order has time of 1350
• Working DiagnosisYES
• Pneumonia at 1330 is prior to 1350 the
  established time of admission for this case.

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Time of Admission Examples

• No diagnosis from ED-HP by Dr. Doctor lists
  possible pneumonia as admission diagnosis.
• There is no dictated time on the HP.
• Dr. Doctor is not mentioned on the ED record as
  in to evaluate patient or present in the ED.
• Note by ED MD at the time of discharge says Case
  discussed with Dr. Doctor.
• Working Dx NO
• Nothing places writing of Dr. Doctor IN the
  ED. No time on the HP to verify diagnosis as
  prior to arrival.

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Time of Admission Examples

• No diagnosis from ED record.
• Consult by Dr.Doctor at 1315 has pneumonia.
• Admit order has no time, no diagnosis.
• ED record has labeled admit time of 1310 under
  physician order to admit to ICU.
  Working diagnosisNO
• Time of admit is 1310-Dx at 1315 is too late.

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ED Admits Examples

• No diagnosis found on the ED record.
• Admit orders lists Dx as possible sepsis and
  pneumonia-no time.
• Working diagnosisYes
• Since the admitting order is the defining point
  of admission
• A diagnosis found on the admit order is an
  automatic YES with or without a time.

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Working Dx Direct Admits

• Acceptable Sources
• HP
• Admit note
• Physician progress note
• Physician orders

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Working Dx Direct Admits

• As with ED admits a diagnosis found on the admit
  order is an automatic YES with or without a
  time.
• Do not use consults for direct admits.
• Documentation the day of and the day after
  admission may be used.

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Direct Admit Examples

• Patient from physicians office, the admit orders
  12/02 1900 do not contain a diagnosis.
• Initial physician progress note 12/03 0130 by
  pulmonologist states patient has pneumonia.
• Second physician note by admitting PCP 12/03
  1000 lists pneumonia as diagnosis.
• Working DiagnosisYES
• The first diagnosis by the admitting MD although
  found on the day after admission is acceptable.

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QUESTIONS
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Surgical Care Improvement Project
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Surgery Times
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Incision Times

• For the incision time look for the EARLIEST time
  found on ANY OR document (anesthesia, circulation
  notes, etc.) that is an included term from the
  priority list of synonyms for incision time.
• Start with the 1 st priority list and only move
  to priority 2 for op start time if nothing can be
  found from the priority 1. Last priority is
  anesthesia start time.
• Your priority is the list of included terms for
  each category-NOT the document on which it is
  found.

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Priority Order

• 1. Incision time
• 2. Surgery start/begin time
• 3. Anesthesia time

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Surgical Incision Time

• Do not capture unqualified times (i.e. procedure
  1600, start 1600).
• These times must be identified as a start time
  and be identified as surgery or anesthesia start.

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Surgical Incision Time

• First Priority-Incision Time
• BRB (breastbone)
• Chest time
• Leg time
• Skin time
• Sternotomy time
• Symbol used on grid and indicated in the legend
  to be incision time (symbols cannot be used
  without a legend).
• Thoracotomy time

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Surgical Incision Time

• Second Priority-Surgery start/Begin time
• Begin time
• Case start time
• Operation opened
• Operation Start time
• Operating Room start time
• Procedure start time
• Surgery start time
• Tourniquet time
• Tourniquet up, inflated, begin

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Surgical Incision Time

• Third Priority-Anesthesia time
• Anesthesia begin time
• Anesthesia induction time
• Anesthesia opened
• Anesthesia start time
• Anesthesia time
• Induction complete time

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Incision Time Examples

• Anesthesia record chest time1325
• Anesthesia record procedure start-1320
• Circulation record OR start1310
• Circulation record Sternotomy time1318
• Two of the times are from the first priority
  list. Two are from the second priority
  listTherefore enter 1318 which is the earlier
  of the times from the first priority list.

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Incision Time Examples

• Anesthesia record operation start820
• Anesthesia record anesthesia induction0825
• Circulation record OR start0810
• Circulation record surgery start0818
• Three of the times are from second priority list.
  One is from the third priority list.therefore
  enter 0810 which is the earliest of the times
  fro the second priority list.

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Surgery End Times

• Priority order of sources
• Anesthesia record
• Circulation record (includes peri-operative and
  intra operative record)
• Nursing notes
• Operative report
• Progress notes

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Surgery End Time Inclusions
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Surgery End Time

• Using the highest priority source capture the
  earliest time from among the Inclusion for
  Surgery End Time.
• If unable to find a time on the highest priority
  source only then may you move to the next highest
  priority source to capture the end time.

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Surgery End Time

• Unlike the start time an unqualified end time is
  acceptable for surgery end time- i.e.Stop 818
  is acceptable.
• Remember that you want to capture the earliest
  acceptable inclusion-not necessarily the most
  accurate or actual STOP time-i.e.last stitch in
  or dressing time should be entered if earlier
  than an op stop time.

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Surgery End Time

• For Surgery end time your priority is the
  document where you must look first for your
  EARLIEST included synonym.
• You have only one list of terms to look for but 3
  sources that must be searched in priority order
  (just the opposite of the incision time priority
  for included terms that can be found on any
  document).

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Surgery End Time

• If an end time is documented with an exact time
  and also documented on the anesthesia grid in the
  same time internal as the exact time, abstract
  only the exact time.
• Example-op end symbol found on the grid between
  1330 and 1335 but under the notes section case
  stop is written in as 1333.
• Enter 1333 as the exact stop time.

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Questions
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ANTIBIOTICSOR vs. NON-ORDOCUMENTATION
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OR vs. NON-OR Documentation

• Non-OR Documentation includes
• MARs
• Nursing Notes
• IV Flow sheets
• PACU and Recovery Room
• Any medication administration that is not labeled
  as OR or not found on OR documentation.

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OR vs. NON-OR Documentation

• OR documentation includes
• Holding
• Pre-op
• Anesthesia
• OR circulation notes
• Intra-op notes
• OR record

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OR Antibiotics

• If the following documentation is found on non-OR
  documentation (i.e. MAR, PACU or RR) records you
  shouldnt assume the medications were given if
  they are not timed or initialed. If you see the
  following you should go the specific document to
  assume the antibiotic was administered (i.e.,
  given in OR)
• Consult the OR record to assure the antibiotic
  was administered (i.e. given in OR, OR, in
  pre-op, given in holding, in OR, given pre-op,
  pre-op, and holding).

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OR Antibiotics

• Antibiotics on Pre-op or OR physician orders may
  be accepted if they are noted as given or
  done and timed or signed. They do not need to
  have both time and signature as long as it is
  clear that they were given (unlike non-OR
  documentation).

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OR Documentation

• Abstract an antibiotic test dose as a separate
  dose.
• Bacitacin and polymyxin can be given IM as well
  as being used for irrigations.
• In order to capture an antibiotic as chest
  irrigation it must be labeled as a chest
  irrigation for both cardiac and CABG surgeries.

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NON-OR Documentation

• I f hanging or hung is found in nursing
  notes, the documentation must substantiate that
  the med was actually started not just hung to be
  started at a later time.
• Antibiotics on physician orders may ONLY be
  accepted if they are
• Timed
• Signed
• And noted as given or done

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Matching Doses OR Meds

• Antibiotics NOS should be collected from OR
  documentation if the time is different than any
  named antibiotic. This option should also be used
  in the rare situations when the antibiotic name
  is not documented in the entire chart or it is a
  new antibiotic not yet included in the pick list.

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Matching Doses OR Meds

• If an antibiotic is documented more than once
  with no time (even if one is without a route)
  enter only one dose with 99.99 or whatever your
  vendor tool requires for a missing time, UNLESS
  there is documentation clearly indicating they
  are separate doses.
• Dont Match Ancef 1gm IV no time and Ancef 2 gm
  no time
• Do Match Ancef 1 gm IV no time, Ancef 1 gm no
  time

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Matching Doses OR Meds

• If an antibiotic is documented more than once
  (one with a time and one without a time) enter
  one dose with the time unless there is
  documentation they are clearly separate doses.

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Questions ??

• www.qnetexchange.org
• as a resource for data definitions