2022 Adult Learning Inpatient Education: Documentation for Altered Mental Status-Clearing up the Confusion [IEM]

Acute altered mental status is a common symptom in hospitalized patients.  Oftentimes documentation includes symptom terms when results in hospital coding that fails to capture the severity of illness in our patients.

This module will help providers identify the diagnostic terms with ICD-10 codes and needed specification for altered mental status.

This documentation is important to ensure complete and accurate hospital coding which has implications on many metrics that both hospitals and clinics follow to include, but not limited to:  accuracy of primary diagnosis, LOS, DRGs, Readmission, Mortality, PSIs, HACs, and POA indicators.

For further study:

Target Audience

Physicians, Fellows, Residents,  Physician Assistants, Nurse Practitioners, Pharmacists across the system.

Learning Objectives

After participating in this activity, the learner should be able to:

  • Identify which terms used to describe changes in mental status are symptoms and which are true diagnostic terms
  • Review the diagnostic criteria for delirium and learn the specifications needed for accurate coding
  • Identify the specifications for encephalopathy
  • Identify how to document an uncertain diagnosis

 

Commercial Support:

No commercial support was received for this activity.

Course summary
Available credit: 
  • 0.25 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 0.25 Attendance
Course opens: 
03/01/2022
Course expires: 
03/31/2023

Planners/Authors: 

Authors:  This activity was planned, reviewed, edited, and approved for use as the curriculum for the Baylor Scott & White Health organization. 

This activity was planned by the following Baylor Scott & White Medical Center staff:


Author:

Dr. Elizabeth Aguirre, MD, CCDS

Inpatient Clinical Documentation Improvement Program Physician Lead

 

Planners:

Dr. Sunita Varghees, MD

Vice President, STEEP Care, CTX Division

 

Jeffery Clark, DO

Chairman, Department of Neurology

Associate Professor, Texas A&M College of Medicine

 

Melissa Koehler, RHIA, CCS, CCDS

 

Reviewers:

Yoon Sin Kim, DO, CCDS

Inpatient Clinical Documentation Improvement Program Physician Lead

 

Sameera Vohra, MD

 

Jenny Lee, MD

 

Module Creator:
Brittany Gonzales



Disclosure of Relevant Financial Relationships:

*This content is not related to products or business lines of an ACCME-defined commercial interest
**There are no relevant financial relationships with ACCME-defined commercial interests for anyone who was in control of the content of this activity.

 

Accreditation: The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation: The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health, designates this enduring material activity for a maximum of 0.25 AMA PRA Category 1 Credits™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM MOC:  Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program.  It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

By claiming ABIM MOC credit, the physician is giving permission to allow their records to be transmitted to the ACCME for transfer to the American Board of Internal Medicine.

Available Credit

  • 0.25 AMA PRA Category 1 Credit™
    The A. Webb Roberts Center for Continuing Medical Education of Baylor Scott & White Health is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
  • 0.25 Attendance
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