Accidental puncture laceration: Complication or not?

One of the biggest documentation problem areas pertaining to patient safety indicators (PSI), particularly related to PSI 90, stems from accidental puncture and laceration (APL), says Katy Good, RN, BSN, CCDS, CCS, clinical documentation program coordinator at Flagstaff Medical Center in Arizona, which recently implemented a new comprehensive PSI review process.

When Good audited a collection of cases from the previous year, she found a number of APL-related issues, including:

• Lack of queries from CDI for clarification
• Lack of physician documentation
• Lack of proper code assignment for every puncture and laceration as a complication

CDI specialists need to decide whether to query when the physician doesn’t state that the laceration is a complication; what constitutes a complication; what terminology should be used when documenting a laceration that is a complication; and how to effectively educate both coders and physicians.

“The biggest challenges for us so far is what is and what is not a complication, and what doesn’t need to be coded versus what does,” says Good.

The first step is creating a review process. Good’s team—which includes six CDI specialists and a manager— try to catch everything concurrently. Both coders and CDI have their own set of PSI-related duties:

• CDI should be tackling any potential documentation issues related to PSIs, such as whether the present-on-admission status is unclear, or whether a complication exists
• As coders work through the record, when they come across a potential PSI, they put the chart on hold and send it to Good, who then reviews the record within 24 to 48 hours.

Every Tuesday and Friday, the CDI team reviews a report that includes PSI-related codes.

“Right now, we have a lot of people reviewing PSIs, even though the volume isn’t that high,” she says. “In the long run, this hopefully won’t need to happen, but since it is new to the team, we want as many eyes on the records as possible to make sure we don’t miss anything.”

Editor's Note: This article is an excerpt from the November/December 2015 edition of the CDI Journal.