Clinical
Judgment
CJ codes
Judgment
CJ codes
Pt falls while being assisted to bathroom by RN
What is CJ5001
Failure to ensure safety/falls
Floor nurse fails to inform MD of overnight increase in pt's BP
What is CO1005
Communication among providers-regarding pt condition
Pt suffers known complication (colon perf) during colonoscopy
What is TS 4008
Possible technical problem-known complication
Blood sample lost in transit to lab for analysis
What is CS9003
Lack of/failure in system for pt care-Specimen handling/labeling
RN fails to write note in medical record describing a minor pt fall
What is DO3001
Insufficient/lack of documentation-adverse event
Radiologist fails to identify a suspicious lung nodule on chest CT resulting in delay in dx of lung cancer
What is CJ1027
Misinterpretation of diagnostic studies
Pt misunderstands surgeon during pre op discussion and believes she will have no scars (instead of small scars) following laparoscopic cholecystectomy
What is CO2018
Communication btw pt/provider-expectations
MFM Fellow performs late term amniocentesis (32 wks. gestation) to evaluate fetal growth restriction and punctures umbilical cord. Fellow had only performed amnio procedures in early pregnancy (15-20 wks. gestation) and this was first late term amnio he had attempted.
What is TS4005
Technical performance-inexperience with procedure
Radiologist does not include incidental finding of small breast mass in chest CT report
What is CS3020
Failure/delay in reporting incidental finding
MD writes note in medical record 3 weeks after pt death
What is DO1006
Mechanics-delay in documenting
ED MD fails to consult cardiologist for pt presenting with chest pain
What is CJ4001
Failure in obtaining consult
Surgical tech is afraid to inform surgeon about an incorrect surgical count because he/she has repeatedly dismissed staff concerns in the past
What is CO1002
Ineffective communication due to hierarchical issues
ED MD cleans and sutures an arm laceration caused by broken window. Pt returns in one week c/o painful lump under suture line and on exam, a shard of glass from window is found protruding from underneath suture
What is TS3003
Retained foreign body-Wound debris
Pt admitted to floor during pandemic contracts COVID from roommate
What is CS 9100
Nosocomial infection
In a deliberate act to cover up an error, MD changes an existing note in medical record 3 weeks after pt death
What is DO9001
Content decision-altered documentation
MD used latex gloves during physical exam of pt with known allergy to latex.
What is CJ1012
Patient assessment issues-history/physical (known allergies)
Pt emails PCP office with c/o CP and SOB after long flight, however, office staff does not regularly check emails and the email is not seen until after pt is admitted to hosp by another provider with PE
What is CO3002
Email related issues
Surgeon removes mole on wrong cheek during Mohs surgery
What is TS4002
Technical Performance-Incorrect body site
Pt never received biopsy results confirming melanoma and delayed removal of the cancerous mole
What is CS3011
Patient did not receive results
MD writes accurate note in wrong pt chart
What is DO1001
Mechanics- inaccurate documentation in factual information
Surgeon identifies and marks incorrect facial mole on wrong cheek for removal prior to Mohs surgery
What is CJ2015
Selection and Management of therapy-surgical/invasive procedures
Surgeon does not disclose risk of post op infection during verbal consent discussion with pt or in written informed consent document. Pt develops post op infection and is upset at need for prolonged hospitalization
What is CO2003
Inadequate informed consent- surgical/invasive procedures
Pt suffers a nerve injury due to improper injection technique
What is TS4004
Technical performance-inappropriate method of administering drug
Pt w recently diagnosed breast cancer did not show for consult with breast surgeon, neither referring MD or breast surgeon followed up to reschedule appt
What is CS4006
Failure in system for pt follow up after missed appt
Cardiologist saw pt for consult but did not document the encounter
What is DO3015
Insufficient/lack of documentation-review of/participation in care