1. Confirm Encounter type is set to Worker's Comp
2. Visit type should be set as CHART REVIEW
3. Submit by clicking UPDATE TYPE

1. Navigate to NOTES
2. Click on CHART REVIEW tab
3. Enter in notes using created K-phrase by adding period and then the phrase chartreview (.chartreview) to add notes

1. Complete the chart review by replacing all of the red asterisk marks with information
2. Click FINISH when complete

1. Principal Diagnosis
2. Identified Reportable Diagnosis
3. Queries
4. Areas of concern or needed follow-up
5. Explanations or comments for any issues or inconsistencies found within the record
6. Identified date or plans for re-review prior to discharge.

1. Where the diagnosis was found in the record-The sequencing rationale, if multiple conditions could be the principal diagnosis—this could include clinical concerns/focus of care,
2. AHA Coding Clinic® guidance, and
3. ICD-10-CM Official Guidelines for Coding and Reporting

1. Include where the diagnosis was found in the record: “AKI w/ATN; nephrology consult 7/1/18, Dr. Nephro”-
2. Accompanying clinical indicators (labs, diagnostics, assessments) to support the presence and reportability (treatments, medications, etc.) of diagnoses—include sourcing and dates for all information:-“Creatinine rise to 3.5 from baseline 1.6 within 36 hours of CT contrast administration”-Clarification of POA status with clinical support as appropriate:-“Stage 4 pressure ulcer, left hip, POA-Y (nursing admission assessment 6/30/18)”-
3. Flags or indicators for diagnoses providing CC/MCC or HCC, contributing to SOI/ROM, triggering a quality measure, etc. as appropriate to the encounter and purpose of the review:-“AKI with ATN (POA-N)—MCC”-“Stage 4 pressure ulcer (POA-Y)—MCC, HCC”-“CAUTI (POA-N)—HAC

Include:

1. Date of query
2. Supporting clinical indicators
3. method (verbal and /or written)
4. physician response
5. any needed follow up

Example: "7/1/18 Dr. Nephro: Verbal query for ATN related to IV contrast. Physician agreed."

Note: any issues that are to be resolved in a repeat review, examples:

• "CXR 6/30/18 notes right lower lobe infiltrate, white count trending upward to 10,000.”
• “Nursing assessment 6/30/18 0300: Patient demonstrating confusion to place and time. Requiring frequent reorientation.”
• “Blood count demonstrating drop on DOS, EBL 150 cc with large infusion of fluids. Check repeat H&H tomorrow."

Communicate any issues or inconsistencies found within the record, examples:

• Dr. Smith states the patient’s fluid overload is not related to cardiac function”
• “Dietitian states high BMI is not related to obesity—patient has dense muscle tissue."

Flag the record for follow up if necessary, examples:

• "Surgery scheduled 7/1—re-review 7/2”
• “No need for further review unless patient is not discharged 7/1"