Has the condition caused the patient to require additional nursing care and/or monitoring?
Some conditions will cause a patient to require a level of care extra to that of a patient without the condition. An example of such a condition is diabetes. For nearly all admitted patients with diabetes (regardless of the reason for their admission), regular blood sugar level (BSL) tests will be performed. This increases the level of nursing care required. Other examples of conditions that may increase the level of nursing care or monitoring required would include: • Dementia, requiring assistance with activities of daily living (ADLs). • Total blindness, requiring assistance with ADLs. • Quadriplegia, requiring assistance with ADLs. • Paraplegia, requiring assistance with transferring. • Colostomy status, when not managed totally by the patient. • COAD with documentation of regular monitoring of oxygen saturation levels. • Chronic renal failure with documentation of regular fluid balance checks. The important point to remember is that in each case, the coder must decide whether or n
