Mortality Documentation
Diagnoses documented as this have the greatest impact on mortality risk adjustment calculations. A diagnosis can be labeled this retroactively—up to the final progress note during the encounter or by response to a Coding Query.
POA/Present on Admission
A 60-year-old man presented with super-refractory generalized convulsive status epilepticus secondary to traumatic brain injury, requiring intubation and continuous infusions of midazolam and propofol as well as treatment with phenytoin, levetiracetam, ketogenic diet, and an immunotherapy agent. Five days after admission, the patient was found to have darkened urine, creatine kinase level of 52,000 U/L, acute renal failure with metabolic acidosis and hyperkalemia. Which of the following medications was most likely responsible for this complication?
A. Levetiracetam
B. Midazolam
C. Ketogenic diet
D. Phenytoin
E. Propofol
E. Propofol
A 58-year-old obese woman with hypertension, hyperlipidemia, and obstructive sleep apnea has been admitted to the intensive care unit for acute ischemic stroke due to occlusion of the left middle cerebral artery. She was managed with osmotic therapy for the first 5 days after the stroke and was not fed due to the possibility of requiring surgery. The patient was successfully extubated on post-stroke day 6 but has repeatedly failed formal swallow evaluations. Due to a large hiatal hernia, the nasogastric tube’s distal end is noted to be above the diaphragm and has only been used for medication administration. The patient is now post-stroke day 8. Which of the following is the best next step in the management of a patient’s nutritional status?
A. Begin pureed diet and nectar-thickened liquids with strict aspiration precautions
B. Check prealbumin and C-reactive protein to assess nutritional status
C. Continue nothing by mouth status until passes swallow evaluation
D. Start total parenteral nutrition
D. Start total parenteral nutrition
When a patient is nearing end-of-life and a provider renders palliative care services for Z51.5, which two things should providers document AFTER they occur, and avoid only documenting as a ‘future’ plan?
The patient transitioned to comfort care and at least one palliative intervention done
A 67-year-old woman was admitted to the intensive care unit with seizures. Her seizures were well controlled with levetiracetam, but she developed aspiration pneumonia and remains intubated for hypoxic respiratory failure. Patient is being treated with continuous propofol infusion and oxycodone as needed. After a few days of mechanical ventilation, she continues to be restless, awake all night, and somnolent during the day. Addition of which of the following agents is the most appropriate next step in management?
A. Atorvastatin
B. Dexmedetomidine
B. Dexmedetomidine
A 52-year-old woman with a prior history of hypertension and opiate use disorder is admitted to the intensive care unit following cerebellar hemorrhage for neurologic monitoring. She is awake, complaining of severe nausea and vomiting, and has difficulty walking. On hospital day 3, she is still unable to tolerate enteral intake except for oral medications. Her medications are methadone, amitriptyline, atenolol, acetaminophen, ondansetron, and prochlorperazine. That evening she becomes agitated, attempting to get out of bed and pulling at telemetry leads. She receives a dose of intravenous haloperidol which is effective in sedating the patient. Thirty minutes later, she develops a polymorphic wide complex tachycardia with varying amplitude which persists for 20 beats then resolves. Blood pressure is 108/64mmHg and pulse is 64/min. The nurse provides you with an electrocardiogram which demonstrates a QTc interval of 540ms. What is the next most appropriate step in management?
A. Administer bolus dose of amiodarone
B. Administer intravenous magnesium
B. Administer intravenous magnesium
For diagnoses from other services—such as Dietary assessing Malnutrition or a Radiology impression noting Cardiomegaly—it’s important for the primary service to do this, so that Coders can accept it.
Endorse the diagnosis in a note.
A 66-year-old woman with diabetes mellitus and hypertension, has been in the neurointensive care unit for one month with refractory status epilepticus secondary to autoimmune encephalitis. Her current medication regimen includes valproic acid, lacosamide, and levetiracetam. She is also receiving immunotherapy with IV rituximab. Her EEG showed diffuse slowing with resolution of her seizures. The patient developed Klebsiella pneumoniae ventilator-associated pneumonia and was started on meropenem. Which important medication interaction should be considered in this case?
A. Meropenem inhibits clearance of lacosamide
B. Meropenem enhances the renal clearance of levetiracetam
C. Rituximab decreases the efficacy of meropenem by inducing its metabolism
D. Meropenum rapidly decreases valproic acid concentration
D. Meropenum rapidly decreases valproic acid concentration
When documenting diagnoses with different stages or additional qualifiers, it's important to do this when clinical documentation supports it (e.g. AKI vs. AKI w/ ATN in a patient with septic shock). This accurately captures the level of severity of the disease and supports accurate risk adjustment.
Document to the highest level of specificity
A 62-year-old woman with uncontrolled hypertension presents to the emergency department with acute onset left sided weakness and a right thalamic intracerebral hemorrhage confirmed by CT imaging. Her blood pressure is 248/123 mmHg and nicardipine infusion is started. Despite treatment, no significant change in blood pressure is seen, yet her Glasgow Coma Scale score drops from 14 to 8. Hematoma expansion is suspected, and she requires intubation. Which one of the following options is the most effective in blunting the reflex sympathetic response and preventing an ICP surge?
A. Ketamine and lorazepam
B. Etomidate and succinylcholine
C. Fentanyl and lidocaine
C. Fentanyl and lidocaine
Reviewing and updating this Epic list of chronic diagnoses allows the care team to easily track focus populations including Heart Failure, COPD, CKD. This promotes continuity of care between Encounters, identifies high-impact POA conditions early and prompts compliance with metrics and KPIs like Guideline-Directed Medical Therapy (GDMT), Readmissions, and more.
The Problem List