Clinical Documentation Tip Sheets

PSI-11 POSTOPERATIVE RESPIRATORY FAILURE:

Inclusions: Post-procedural respiratory failure following “ELECTIVE” admission.

Exclusions: Neuromuscular Disorders e.g. Myopathy. Neurological Disorders e.g.. Dementia, Delirium (POA).

Tip: Document Acute Delirium instead of altered mental status.

Tip: Avoid: “ Post-op respiratory failure ” for patients expected to be intubated after surgery

PSI-12 PERIOPERATIVE PULMONARY EMBOLISM OR DVT:

Inclusions: Post-operative pulmonary embolism. Post-operative deep venous thrombosis.

Exclusions: Brain or Spinal Cord Injury. DVT of Distal Veins of Lower Extremities. Single subsegmental PE

Tip: Always specify t he Vein of the DVT and the type of the PE

PSI-13 POSTOPERATIVE SEPSIS:

Inclusions: Post-operative Sepsis following “ELECTIVE” admission.

Exclusions: Sepsis and/or any infection present on admission (POA)

Tip: Always document the POA status of sepsis.

Tip: Document S IRS instead of sepsis or Sepsis ruled out if no source of infection identified

PSI-15 ABDOMINOPELVIC ACCIDENTAL PUNCTURES OR LACERATIONS:

Inclusions: Accidental puncture or laceration during a procedure, and Corrective procedure was done >= 1 days after the index procedure. Exclusions: Documentation that the puncture or laceration was expected outcome, inherent to the procedure or not clinically significant