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dvoegele

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Posts: 10
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Patient comes in altered mental status....history of diabetes and alchohol abuse.  Lab work is done and and finger stick....and medications infused patient feeling better.  Diagnoses hyperglycemia and uti.
Would this be New problem; no additional work up planned or established problem worsening.
I read also that New problem: additional workup planned (er setting) is typically when patient is being transferred to a higher level of care, i.e observation, inpatient or transferred out
pjensen

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Reply with quote  #2 
I think the hyperglycemia would count as a new problem with no further w/u needed.  The UTI can go either way.  If you are going to send culture, then it would probably be considered a new problem with further w/u required.  If you are just going to treat empirically, then probably new problem with no further w/u.  Unfortunately, there is a limit of ONE new problem with no further w/u which can be tallied per encounter. 

On the other hand, if you have seen the patient before for management of diabetes, then the hyperglycemia would be considered an established problem which is worsening.

I have not heard any guidance about "additional work-up" requiring a change in status of the patient from obs to inpatient, etc.
dvoegele

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Reply with quote  #3 
Can you tell me what qualifies for new problem
Additional work up needed
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