Expected Mortality

• CHF, COPD & Afib– WOB, Sats, RR– BiPAP– ABG results– Thin, sunken temples– BP, gtt’s started

• Expected Mortality Rate:

1.7%

• CHF, COPD & Afib• ADD:

– Respiratory Failure– Acidosis– Decubitus ulcer– Malnutrition– Cardiogenic Shock

• Expected Mortality Rate:

36.3%

Expected Mortality

– PNA – Acute COPD

– Mortality Rate:

0.3%

– PNA – Acute COPD

– Add:• Malnutrition• Decubitis Ulcer

– Mortality Rate:

2.3%

– PNA – Acute COPD

– MODIFY:• Malnutrition, SEVERE• Decubitis Ulcer,

STAGE IV

– Mortality Rate:

9.2%

• HCAP translates / codes to

Simple pneumonia

• Consider:PNA, possibly due to:

• gram negative organism• Specific suspected organism

• The Extra Step:

• Include ALL chronic conditions –present and stable but managed

• Cancer• Primary vs Secondary

• Specify ALL metastatic sites

• Active … Remission … Resolved

–Include all associated diagnoses

• Urosepsis translates / codes to

Simple UTI

• Consider:

Sepsis from a UTI

• The Extra Step:

• For each medication–Associated diagnosis

• For each ordered study–Suspected diagnosis

• When is a PE resolved??

–If PE is felt still present & being treated:• Identify as acute or subacute

• Even if from a recent admission

• ACUTE CHF translates / codes to

CHF, not further specified

• Consider:

Specify diastolic &/or systolic

Will then capture ACUTE

• The Extra Step:• For each abnormal finding

• (Lab, radiology, exam)

• Describe clinical significance

• INCLUDE suspected cause

• NAME IT

• ESRD• With fluid overload or pulmonary edema

–Is it NON-CARDIOGENIC?

–Or is it CHF• What is the cause (non-compliance?)

• END STAGE COPD with continuous home O2

translates / codes to

COPD only

• Consider: • COPD, Acute Exacerbation

• Acute & Chronic Respiratory Failure

• The Extra Step:

• Specify supportive facts for diagnosis

• Quantify Risk Stratification

• History of…??

–Is the condition truly resolved?

Or is it chronic & stable with ongoing management

• “Post-operative” Frequently translates / codes to

complication

• Caution on intended meaning: • Temporal vs Causative relationship

• Clarify if INTEGRAL to procedureor EXPECTED part of recovery period

• The Extra Step:

• Include ALL diagnosis being considered, worked up or treated

• “possible”, “probable”, “likely”• Update diagnosis status

– Ruled in or out– Remains possible

• Altered Mental Status: Is it?• Acute Confusion

• Chronic dementia…or acutely worse?

• Acute delirium

• Encephalopathy

–Include specific suspected causes

• Symptoms (dyspnea, chest pain, dizziness, weakness,

fever) translates / codes to

????• Explicitly state suspected cause

– d/t arrythmia, COPD, CHF, PNA, etc.– d/t unstable angina or CAD, pleurisy, GERD, chest wall pain– d/t hypotension / dehydration– likely source, or bacterial infection unknown source

• The Extra Step:

• Relate conditions & State connections–UTI due to Foley–specific conditions due to prior CVA–Manifestations & Sequela

• Manifestations of diseaseWITHOUT Explicit linkage

translates / codes to

Uncomplicated DM, HTN

• Consider – use adjective or “due to”• Diabetic nephropathy or Hypertensive CHF

• The Extra Step:• Carry diagnoses throughout stay

• Include ALL diagnoses at discharge• Acute

• Chronic

• Resolved during stay

• Condition with “VS” (differential diagnoses)

translates / codes toCondition ONLY

• Consider: 1. Identify primary suspected cause

(then follow with alternatives)2. Clearly indicate RULED IN & OUT diagnoses

• Use STRONG terms:• Failure

• Shock

• Coma

• Encephalopathy

• The Extra Step:

• Renal Status–CKD Stage?–Acute Renal Failure due to …

• Use STRONG Qualification & Links:

• Acute, Acute on Chronic• Sub-acute, Chronic

• Congenital• Exacerbated• Uncontrolled

• Mild, Moderate, Severe• Due to, Secondary to

• Unstable

• The Extra Step:• Abbreviations

–Always spell it out the first & last time–Different areas expertise & knowledge

• Prevent confusion & errors