APDC: Spotlight on burns

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ICD-10-book-cover-for-APDC-series-labelBurns are common conditions seen in the Emergency Room (ER) / Department (ED) when a traumatic injury results in tissue loss or damage on body region(s). Caroline and Mary (2012 p. 1206) classify burns “according to the mechanism of injury and according to burn depth and size”,

An example of an ER / ED case is when a 56 year old man presents with an  electrical burn while undertaking mechanical repairs to his car when his metal wrist watch had made contact with part of the electrical system. Although electrical burns can be potentially life threatening, especially if caused by electric shocks due to exposure to electricity current or lightning, this patient experienced immediate pain from an injury to the radial aspect of his right wrist with subsequent skin changes and discomfort at the periphery of the lesion.

Image credit: BMJ 2013;346:f2856

The ER / ED doctor will assess to estimate the total body surface area and depth of this burn as seen from the photograph (left), and manage this ED / ER case.

Other common examples of burns seen in the ER / ED are thermal burns as a result of direct contact with heat sources – example caused by steam, hot water scalds, and flames, electrical burns as well chemical burns caused by exposure to strong acids,
alkalis, or other substances such as detergents or solvents especially affecting the skin and eyes, and radiation burns from exposure to radioactive sources, such as the ionizing radiation used in industry, or therapeutic radiation.and sunburns.

The International Classification of Diseases (ICD), 10th Revision: Version 2010 provides several codes to classify burns.

Burns are classified under the Chapter XIX Injury, poisoning and certain other consequences of external causes (S00-T98) and spread across three (3) blocks, from T20 to T32.

From within the codes from T20 to T32 for burns under the Chapter XIX, they are grouped into three (3) groups, namely codes from burns of external body surface, specified by site (T20-T25) – example of a site is the head and neck site, to burns confined to eye and internal organs (T26-T28), and burns  of multiple and unspecified body regions (T29-T32).

Health Information Management (HIM) / Medical Records (MR) practitioners must take note that when the site of the burn is unspecified but the burn is  classified according to extent of body surface involved, then the codes from T31 category is to be used as the primary code only . However, it may be used as a supplementary code, if desired, with categories T20-T25 or T29 when the site is specified. 

Image credit: TBSA rule of nines, Caroline and Mary (2012 p. 1208)

Doctors who record the assessment for burns use some modification of the “rule of nines” (as above) for estimating percentage of body burned from the total body surface area (TBSA). The body is divided into multiples of 9%. For instance, one arm equals 9% and the entire back equals 18%.

HIM / MR practitioners must also be aware of the codes assigned to sequelae (a residual condition) of burns, corrosions and frostbite at T95.

References:

  1. Caroline, BR & Mary, TK 2012, Textbook of basic nursing, 10th edn, Wolters Kluwer Health, Lippincott Williams & Wilkins, Philadelphia, USA
  2. Mitchell, CJ, Ahmad, Z and Khan, MS 2013, An unusual burn, Endgames, 25 May 2013, vol. 346, British Medical Journal, BMJ Publishing Group Ltd, London
  3. World Health Organization 2011, Volume 1 Tabular list, International Statistical Classification of Diseases and Related Health Problems 10th Revision, 2010 edn, Geneva, Switzerland

Nutrition therapy and the medical record

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Patients are screened for nutritional risk as part of the initial assessment with the application of screening criteria to gather information on nutritional status or functional status – often done by nurses, which must also be completed routinely within 24 hours of admission to the hospital or at an earlier time period.

I had covered at length on this requirement as you can follow from the posts (each of the following links will open in a separate new tab of your current browser window) Hospital screening criteria data to identify patients with nutritional or functional needs and 6 steps in documenting hospital screening to identity patients with nutritional or functional needs.

A patient identified with nutritional or functional needs i.e. at nutrition risk, is referred to a nutritionist for further assessment and a collaborate plan for nutrition therapy is carried out by doctors, nurses, and the dietetics service, and when appropriate with the help of the patient’s family. The nutritionist monitors at intervals the patient’s progress from the nutrition therapy, the nutritionist’s reassessment throughout this special care process is part of all reassessment by all the patient’s health care practitioners as the key to understanding whether care decisions are appropriate and effective, and records the progress in the patient’s record.

So what is nutrition therapy?

A patient is after a burn or surgery. Another patient is with a high fever, or suffering from acute diarrhoea. Yet another patient is with diabetes mellitus, a disorder throughout life. One other patient is suffering an acute illness with coronary or vascular disorders.

Nutrition is a vital component of therapy for the above listed disorders. According to (eds. Catherine, Benjamin, Robert, Katherine, & Thomas 2014, p. 1162), “use of the term therapy recognizes the role of nutrition in affecting patient outcome and acknowledges the demonstrable risks and benefits to nutrition intervention in both the short term and the long term.”

So, nutrition therapy is required with a high protein intake to rebuild, repair and heal body tissues after a burn or surgery. Nutrition therapy is provided when a patient needs fluids and electrolytes to replace what is being lost due to haemorrhaging, vomiting, and perspiring profusely. Because most serum glucose depends on dietary intake, nutrition therapy is a vital component in the prevention and management of diabetes mellitus which necessitates a special diet plan. Nutrition therapy  is again necessary with a special diet limiting or modifying the fat and sodium intake for a patient with coronary or vascular disorders.

Thus, Health Information Management (HIM) / Medical Records (MR) practitioners will find within medical records, progress notes with the nutritional care of the patient met in accordance with the doctor’s orders which includes the nutrition therapy, and the patient’s progress from the nutrition therapy documented by the nutritionist.

I think medical records will only be complete if a patient at nutrition risk undergoing nutrition therapy has his or her medical record showing progress notes from the nutrition therapy documented by the nutritionist. This particular instance of medical record completeness must be satisfied irrespective of your type of hospital, either it is or it is not already Joint Commission International (JCI) accredited or seeking JCI accreditation status or undergoing re-survey for JCI accreditation status, but if it is, then your hospital will need to comply with JCI Standard COP.5 which requires that “Patients at nutrition risk receive nutrition therapy.”

If JCI Standard COP.5 and its four (4) Measurable Elements are complied satisfactorily, then your medical record also complies with the JCI Standard MCI.19.1 which states that “The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify the treatment, to document the course and results of treatment, and to promote continuity of care among health care practitioners.”

Before I end, some of you may be wondering what’s the difference between a dietitian and a nutritionist? I am not going to elaborate much on this but since I have used the terms dietitian and nutritionist in three related posts on nutrition,  I know for certain that dietitians and nutritionists are both food and nutrition experts respectively. You may find out more on dietitians and nutritionists from the Academy of Nutrition and Dietetics (United States) and from the University of Maryland Medical Center, United States. Some say dietitians are considered to be nutritionists, but not all nutritionists are dietitians.

References:

  1. Catherine, AR, Benjamin, C, Robert, JC, Katherine, LT & Thomas, LT (eds.) 2014,  Modern nutrition in health and disease, 11th ed, Lippincott Williams & Wilkins, Philadelphia, USA
  2. Joint Commission International, 2010, Joint Commission International Accreditation Standards For Hospitals, 4th edn, JCI, USA
  3. Sylvia, ES 2012, Nutrition and diagnosis-related care, 7th edn, Lippincott Williams & Wilkins, Philadelphia, USA

Flavius and Septimus

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Last night I stumbled upon this article about change and when one crosses over into the Twilight Zone, from the Healthcare Information and Management Systems Society (HIMSS),  head-quartered in Chicago, and with additional offices in the United States, Europe, and Asia, is a cause-based, not-for-profit organization global enterprise producing health information technology (IT) thought leadership, education, events, market research and media services around the world, focused on better health through IT.

I think the story strikes an analogy that is relevant to everyday challenges in life and to any profession  as we struggle  to transition from the present which is rooted in the past (as we cling on the present so stubbornly because we fear change) to the future with a vision.

The story is of a man at work, Gaius Flavius Lautumiae who is the emperor’s royal stonecutter, stone-cutting has been the only work he knows and ever known in his whole life. The scene – the emperor’s royal quarry where Flavius is working on a stone monument for the recently deceased emperor.  The dialogue with his close friend, Septimus goes like this ….…

SEPTIMUS: But Flavius, the whole world, all of civilization has made the change.  Even the Celts!  Think about it: even the primitive Celts have gone over.
FLAVIUS: I tell you, Septimus, it matters not which barbarian hordes have changed their ways!  We Romans have been using these numbers since the time of Julius Caesar, even before the emperors came to be.  If it was good for them, it is good for us, and it will be good for our children.
SEPTIMUS: Flavius, come to your senses.  You know that the royal son will become the emperor after that stone you are cutting has been set in place.  We have all been warned that he comes to the palace with countless scrolls filled with writings telling us about new ways to do many things.  The new ways will become our ways.  It will be decreed.
FLAVIUS: Septimus, you should know that it was the old ways that got us here, and it will be the old ways that take us to tomorrow.
SEPTIMUS: But Flavius, have you even looked at the new numbers?  They are amazing!  One simple stroke and a value can be recorded.
FLAVIUS: Bah!  You call all of those circles and curves simple?  They’re a nightmare!
SEPTIMUS: As a stonecutter, you may see it that way. But everyone who has made the change attests that the new numbers are a wonder.  A wonder!  They open many new vistas for us. This new system will allow our civilization to progress. Without it, I fear that Rome may no longer be… Rome.
FLAVIUS: I cannot accept the change.  I see no reason to change.  I care not for new vistas; I just desire to cut my stone with simple, straight lines.

Flavius is an example of an individual who continues to live in the yesterday, its memories are all that is what he wants, yesterday is what he will get and tomorrow will never come for him.

Is CHANGE good or bad?

Georg  C. Lichtenberg  (1 July 1742 – 24 February 1799), who was a German scientist, satirist and Anglophile (a person who greatly admires or favours England and things English) once said “I cannot say whether things will get better if we change; what I can say is that they must change if they are to get better.”, and I trust him so just to take him at his word.

References:

  1. No Time Like the Past, News, Healthcare Information and Management Systems Society (HIMSS), viewed 29 May 2013, <http://www.himss.org/News/NewsDetail.aspx?ItemNumber=18547>

18th IFHIMA Congress – October 2016 Tokyo, Japan

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The 18th Congress of the International Federation of Health Information Management Associations (IFHIMA) will be held during October 2016 in Tokyo, Japan.You can view images of the just concluded 17th IFHIMA Congress in Montreal, on May 11-15, 2013 from this link (this link will open in a new tab of your current browser window).

Personal Data Protection Act 2010 – Introductory Post

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PDPATo continue to create value for readers of this web-blog, I shall be offering through a series of posts on the Malaysia Act 709 Personal Data Protection Act 2010 (PDPA). The Act was passed by the Parliament on May 2010 and gazetted into law in June 2010.

Malaysia is not the only country with a new act of  law on privacy of data, so do take a look at the list from http://www.informationshield.com/intprivacylaws.html (this link will open in a new tab of your current browser window) which contains a number of international privacy related laws by country and region.

So much has been written already on PDPA ever since 2010, and readers can easily surf the Internet to know about this Act. So it is pointless for me to repeat topics to create awareness about this Act, for example the 7 Principles according to the PDPA requirements, and offenses and liabilities of PDPA. In fact you can scrutinise a copy of this Act which is available from “The Download List” at http://mrpalsmy.com/resources-2/the-download-list/ (this link will lead you to the act on the page “The Download List” in a new tab of your current browser window).

My concern is to examine PDPA through this series of posts, both the direct and indirect impact to healthcare in general and Health Information Management (HIM) / Medical Records (MR) practices specifically.

My plan is bring you what I understand and give my interpretation as I see it from the requirements of PDPA, right from the start of the Act 709 documentation, section by section. As I dissect the Act 709, I hope to bring you examples of both the direct and indirect impact(s),  gaps in data processing and protection from within and outside this Act, perhaps  make an attempt to identify a hospital’s  organisational maturity plan for PDPA, and of example techniques for acceptable use of personal data against the PDPA which are amongst some areas of concern I have given thought to, and which I hope to cover in due course.

I believe that Health Information Management (HIM) / Medical Records (MR) practitioners are already aware for the need to ensure proper governance of data and information even before PDPA was an act of law in Malaysia. While I already know, and I am sure you also already know too that the PDPA is aimed at regulating the processing of the personal data of an individual who is involved in commercial transactions, I still think it is wiser to be informed about PDPA although HIM / MR  practitioners have been and are still required and regulated by professional ethics, guidelines, regulations and best practices of their organisation (hospital) to provide protection to the individual’s personal data and thereby protect the interest of the individual concerned.

I shall be as non-technical in preparing the posts (as after all I am not a solicitor) and I hope to cater to the local HIM / MR management and executives who are dealing with day to-day personal healthcare related data processing. At the end of the series of the posts, I hope you and me will have a better understanding of what is PDPA, why it is important, where it fits into the hospital as an organisation and how to take the necessary steps to address it.