Thursday, September 29, 2016

Who is Obese? 5 Dangers of Obesity

The healthcare community has defined obesity as a body mass index (BMI) of 30 or more. The BMI is the ratio between the weight of a person (in kilograms) and the square of the height (in meters). There are many calculators online that can calculate the BMI using pounds and feet/inches. This is a very inexact way of classifying overweight people because there could be very muscular people that could be obese according to this definition. In addition, it may cause shorter people to be overrepresented in the obese population.  In spite of this, the BMI provides an easy way of classifying people according to weight that can lead to meaningful research and can serve as an effective screening tool.

There are many dangers that originate from being obese. I will list here the five most relevant ones

1. Diabetes mellitus. Having excessive adipose tissue causes insulin resistance and some obese people may become diabetic because of this.

2. Hypertension. Obesity is associated with hormonal variations that may lead to salt and water retention and constriction of small arteries. These changes can elevate the blood pressure.

3. Sleep apnea.  This condition is related to obesity. It causes the breathing to stop many times during the night causing problems with oxygenation and getting rid of carbon dioxide.

4. Osteoarthrosis. The extra weight that the obese person has to carry has an impact on the hip and knee joints. This may lead to incapacitating pain and joint replacement surgeries.

5. Cancer. Breast, colon, gallbladder and endometrial malignancies are more common in overweight individuals than in people with normal weight

Diabetes and hypertension are  significant risk factors for coronary artery disease and stroke. Sleep apnea is directly related to hypertension. This means that obesity may impair a person’s health in multiple ways.

Marco A. Ramos MD

Wednesday, September 14, 2016

Tips for Great Clinical Documentation Part 3

In the previous post of the series, I outlined the importance of using the terms “probable”, “possible”, “likely” and “not ruled out” when documenting in a medical chart. In this post I am going to highlight the importance of being consistent with the diagnoses throughout the duration of the record.

Be consistent with diagnoses throughout the record.

In clinical practice, a provider, as seen in the previous post, can make decisions and place orders based on a probable diagnosis. As the days pass and more clinical data is available, most of those diagnoses will be clarified and the decision-making might change or remain the same. For this reason, it is important to document what happened with the initial “probable” diagnosis. The use of the term “ruled out” is very useful because it tells the coder that what we initially thought was probable, it is not a possibility anymore. In a case of “probable pneumonia” in the first day, the record may read on the second day: “Pneumonia was ruled out”. This implies that antibiotics are not being used anymore, so the chart would reflect proper allocation of resources.

The other situation that needs to be taken into account is the one that results from the resolution of a problem. This is particularly important in prolonged hospitalizations, when problems that were there originally, end up being resolved. It is good practice to carry the diagnosis in the assessment section and document “resolved”. This has the added benefit of letting providers that  arrive later in the picture, that a patient had a problem and it is not present anymore. With respect to the allocation of resources, it is different to document “resolved” that to document “ruled out”. “Resolved” means that the problem was there and was corrected using the treatments ordered by the provided. “Ruled out” means that the problem was never there and any continued use of resources is not justified. A document may read like this: “Hyponatremia. Present on admission, resolved.”

Marco A. Ramos MD
Second Medical Opinions PLC

Physician Advisor in Clinical Documentation