Note from the CCDS Coordinator: ‘As God as my witness’ there’s a query opportunity here

by Penny Richards

Can you begin to imagine how complex a piece of great literature would be in we had to include complete documentation of each medical incident? Or have to stop every time we have to develop physician queries?

Let’s take a look at the classic tale Gone with the Wind and see whether we can identify some areas where author Margaret Mitchell might have given us more information.

• Scarlett O’Hara’s first husband Charles Hamilton dies of pneumonia. Viral? Bacterial? What was the treatment plan?
• Countless soldiers are wounded and dying in makeshift hospitals. Are there coding concerns about where the injuries occurred, specifically with regard to which state the patient resides in (as the bills may go to different fiscal intermediaries)? What about POA or the possibility of readmission?
• Scarlett learns her mother is ill but because of the war, Scarlett can’t get home to see her mother. Might Scarlett be experiencing stress and anxiety?
• Melanie Wilkes gives birth to a baby boy, Beau. No physician is present for the delivery. Can we assume a physician saw mother and child for post-delivery examination?
• Scarlett finds that her father Gerald has lost his mind. Is there a diagnosis of dementia or Alzheimer’s? Is it post traumatic stress disorder or due to an injury suffered during the war?
• Gerald dies of injuries from a fall off a horse. Do we need to indicate where the event took place?
• Ashley Wilkes is shot in the retaliation attack. Where was the wound? What procedures were performed?
• Frank is killed in that same attack. Poor Frank. He really thought Scarlett loved him. Poor Suellen who never stopped carrying a torch for him. She was likely given a sedative and put to bed. Injection? Infusion? Shot of brandy?
• Scarlet marries Rhett Butler and has his baby. Are there any complications noted?
• Scarlett, pregnant again, falls down a flight of stairs and miscarries. What is the trimester? Does she suffer injuries in addition to the lost pregnancy? What drugs are administered for her injuries? Is there a plan for physician follow up? Are any specialists called in for consultation? Did she fall or was she pushed?
• Their daughter, Bonnie Blue, falls from her horse and dies of her injuries. What is the actual cause of death and how should her other injuries (if there were any) be noted in the record?
• Melanie is ill, suffers a fall, and never recovers. She dies. Did she fall due to the illness or injuries from the fall? What conditions were present on admission to the good doctor’s care?
• Ashley has a broken heart. How should this be documented for appropriate coding?
• Rhett walks out on Scarlett. She weeps and then pulls herself together and declares that tomorrow is another day. Does anything indicate that Scarlett may be suffering from delusions? The vapors?

What do you think? Do you have any other suggestions for movies or literature that we could probe for clinical documentation opportunities?

Editor's note: Richards is the CCDS Coordinator at ACDIS. Contact her at prichards@acdis.org.