Hepatic disorders
By Julie Shayne RN, CCDS, Intermountain Peaks Clinical Documentation Integrity Educator
Documenting the specificity of hepatitis and cirrhosis, as well as its associated conditions, when clinically significant accurately supports the intensity of your service, severity of illness, risk of mortality and risk-adjustment metrics.
Hepatitis:
Specify acuity > acute or chronic
Specify etiology > alcohol/other drug (specify) or viral (specify type A, B, C, E)
Document any associated conditions:
Cirrhosis
Hepatic failure (specify acuity > acute, subacute or chronic, and specify with or w/o coma)
Portal HTN
Esophageal varices (specify with or w/o bleeding)
Hepatocellular carcinoma
Cirrhosis:
Specify etiology > alcohol, viral (Hep B, C or D), cryptogenic (NASH), autoimmune, hemochromatosis, etc.
Document any associated conditions:
Ascites
Hepatic failure (specify acuity > acute, subacute or chronic, and specify with or w/o coma)
Portal HTN or portal vein thrombosis
Esophageal varices (specify with or w/o bleeding)
Spontaneous bacterial peritonitis
Hepatic failure (specify acuity > acute, subacute or chronic, and specify with or w/o coma)
5-day LOS: Medical case impact w/o and with cause and specificity of liver failure
Thank you for your attention to documentation and the expert care you provide every day. Please contact me at julie.shayne@imail.org with any questions.
Integration update: Functions formerly known as the Quality Department, Patient Experience and Clinical Documentation Integrity teams in the Peaks Region have been aligned with the Desert and Canyons Regions and reestablished as Clinical Excellence at Intermountain Health. The new term – clinical excellence – aligns with the committee of the board that supports these areas of clinical focus and is also the shared goal of the team supporting work to further clinical excellence and positive outcomes for patients, clinicians and care team members.