DOCUMENTATION CLARIFICATION QUERIES

These sample physician query documents are offered solely as examples of standardized physician queries to clarify clinical documentation within the medical record. These query documents were created based on our interpretation of AHIMA/ACDIS guidelines and may be used by healthcare facilities at their own discretion.

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Recommendations for use: These query templates are designed for use as Word documents or e-messages and the content is to be edited and customized for the specific findings in each case. Suggested indicators not present in a particular case and/or multiple choice response options not supported by indicators (e.g., acute heart failure with only chronic indicators) should be deleted prior to submission to the provider. Content within brackets should be completed or deleted. Titles of each template are for reference only and should not appear on queries submitted to providers.

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DOCUMENTATION CLARIFICATION QUERIES

Table of Contents

Topic / Page No.
Acute Coronary Syndrome / 3
Acute Kidney Injury (AKI) / 4
Acute Tubular Necrosis / 5
Anemia, Acute Blood Loss / 6
BMI 40 / 7
BMI < 19 / 8
Chest Pain / 9
CHF – specify type only / 10
CHF – specify type and acuity / 11
CKD Stage / 12
Debridement, Excisional / 13
Depression / 14
Diabetic Gastroparesis / 15
Diabetic Complications / 16
Encephalopathy / 17
Encephalopathy causing Delirium / 18
Functional Quadriplegia / 19
GI Bleeding / 20
HIV/AIDS / 21
Hypertension (Crisis / Emergency) / 22
Malnutrition, severity / 23
Malnutrition, not yet diagnosed / 24
Pathologic / Osteoporotic Fracture / 25
Pancytopenia / 26
Pneumonia, Healthcare Associated (HCAP) / 27-28
Pneumonia, Aspiration / 29
Pressure Ulcer / 30
Respiratory Failure, Acute / 31
Respiratory Failure, Chronic / 32
Schizophrenia / 33
Sepsis / 34
Syncope / 35
TIA / 36
Urosepsis / 37
Probable/suspected cause of symptoms / 38
Specific diagnostic condition / 39
Clarification of a conflicting diagnosis / 40
Confirmation of a diagnosis / 41
Clinical validation query / 42
General query template / 43

[Acute Coronary Syndrome]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having ACUTE CORONARY SYNDROME.

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following this condition is intended to indicate:

·  Transmural MI

·  Subendocardial MI

·  STEMI

·  NSTEMI

·  Unstable angina

·  Other diagnosis (please specify)

·  Not applicable / none of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

[Acute Kidney Injury]


Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having______.

The following lab is also documented in the medical record:

Creatinine on admission = ______ Baseline creatinine [if known]: ______

Correction of creatinine from ______to ______following rehydration

Creatinine increasing from ______to ______between ______and _____ [dates]

Urine output ______cc over ____ hours [if >6 hours and meets cc/kg/hr criteria]

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following these findings suggest:

·  Acute kidney injury (AKI) / acute renal failure

·  Acute on chronic renal failure

·  Chronic kidney disease / chronic renal failure (Please specify Stage)

·  Other condition

·  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[Acute Tubular Necrosis (ATN)]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having Acute Kidney Injury (AKI).
Include the following clinical findings, as applicable, which support the query for ATN:

·  Prolonged elevation of creatinine (> 72 hours)

·  Oliguria (low urine output specified in cc/hr over what time period)

·  Hypotension (include specific blood pressure readings)

·  IV contrast administration

·  Nephrotoxic medication

The following is also documented in the medical record:

·  Serial creatinine levels [and dates]:

·  FENa =

·  Urinary sodium concentration:

·  Urinalysis [if applicable]:

·  Other circumstances:

Based on your medical judgment, can you further clarify in the progress notes the likely cause of the acute renal failure or insufficiency in this case such as:

·  Acute Tubular Necrosis

·  Acute Cortical Necrosis

·  Acute Glomerulonephritis

·  Pre-Renal Acute Kidney Injury/Renal Failure

·  Another condition (please specify)

·  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

[Acute Blood Loss Anemia]

Documentation in the medical record indicates the following:

·  Anemia

·  Drop in Hgb from ___ to ___

·  GI bleeding

·  Hypotension

·  Blood transfusion of __ units

·  Other

Based on your medical judgment, can you further clarify in the progress notes which,
if any, of the following conditions are responsible for these findings:

·  Acute blood loss anemia

·  Chronic blood loss anemia

·  Acute on chronic blood loss anemia

·  Acute hemorrhagic anemia

·  Iron deficiency anemia

·  Other anemia (please specify)

·  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[BMI >40]

Documentation in the medical record indicates that this patient has:

BMI =


Other documentation includes:

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are associated with this BMI:

  Overweight

  Obesity

  Morbid obesity

  Other condition (please specify)

  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[BMI < 19]

Documentation in the medical record indicates that this patient has:

BMI =

Other documentation includes:

Based on your medical judgment, can you further clarify in the progress notes which, if any, of the following conditions are associated with this BMI:

  Underweight

  Malnutrition – if so please document severity

  Undernutrition

  Anorexia

  Other condition (please specify)

  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[Chest Pain]

Based on the documentation in the medical record, this patient was admitted with

CHEST PAIN.

Other information in the medical records includes:

Based on your medical judgment, is the chest pain most likely, possibly, probably due to any of the following causes:

ð  Coronary artery disease / ð  Pleurisy / ð  Biliary colic
ð  GERD/reflux / ð  Costochondritis / ð  Anxiety
ð  Dyspepsia / ð  Gastritis / ð  Hyperventilation syndrome
ð  Cholelithiasis / ð  Cholecystitis / ð  Chest wall pain
ð  Esophagitis or spasm / ð  Hiatal hernia / ð  Peptic ulcer
ð  Other diagnosis (please specify)
□ Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[CHF – specify type only]

Documentation in the medical record indicates that this patient is being treated for

HEART FAILURE / CHF.

  Echocardiogram reports EF of ______

  An EF of _____ is documented [location / by whom]

  The patient has a history of [ESRD / Hypertension / Coronary artery disease]

  Medications include:

  Chest x-ray shows:

  BNP =

  Other documentation and findings include:

Based on your medical judgment, can you further clarify in the progress notes the precise nature of the patient’s heart failure/dysfunction for this admission such as:

ð  SYSTOLIC

ð  DIASTOLIC

ð  COMBINED SYSTOLIC/DIASTOLIC

ð  Other (please specify)

ð  Not Applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[CHF – Specify type and acuity]

Documentation in the medical record indicates that this patient is being treated for

HEART FAILURE or CHF.

·  Echocardiogram reports EF of ______

·  An EF of _____ is documented [location / by whom]

·  The patient has a history of [ESRD / Hypertension / Coronary artery disease]

·  Medications include: ______

·  Chest x-ray shows: ______

·  BNP = ______

·  Other documentation and findings include:

Based on your medical judgment, can you further clarify in the progress notes the precise nature and severity of the patient’s heart failure for this admission, such as:

ð  Systolic

ð  Diastolic

ð  Combined

ð  Exacerbation / Decompensation (Acute)

ð  Acute on Chronic

ð  Chronic

ð  Other (please specify)

ð  Not Applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[CKD Stage]

Based on the clinical information documented in the medical record, this patient has been diagnosed with Chronic Kidney Disease, Failure or Insufficiency.

Lab reports show a stable GFR of ____ to ____ from ______to ______.

Stage / GFR
CKD Stage 1 / > 90
CKD Stage 2 / 60 – 89
CKD Stage 3 / 30 – 59
CKD Stage 4 / 15 – 29
CKD Stage 5 / < 15
ESRD / Need for dialysis

Based on your medical judgment, can you further clarify the appropriate stage of CKD in the progress notes?

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[Debridement, Excisional]

Based on the documentation in the medical record, this patient has undergone

WOUND CARE and/or WOUND DEBRIDEMENT.

Based on your medical judgment, can you further clarify the precise nature, depth, extent and/or methods of wound debridement utilized in this case, such as:

ð  EXCISIONAL debridement (use of a scalpel/blade to cut away tissue)

ð  NON-EXCISIONAL debridement (chemical, scrubbing, trimming with scissors)

ð  Other debridement (please specify)

ð  Other / Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[Depression]

Documentation in the medical record indicates that this patient has been admitted with or diagnosed as having DEPRESSION.

The following is also documented in the medical record:

______

Based on your medical judgment, can you further clarify in the progress notes the status of this patient’s DEPRESSION:

Type

·  Major depression

·  Simple depression

Severity

·  Mild

·  Moderate

·  Severe

Remission status

·  In remission

·  Not in remission

·  Other (please specify)

·  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[Diabetic Gastroparesis]

Documentation in the medical record indicates that this patient has been diagnosed with

DIABETES and is being treated for [GASTROINTESTINAL disorder].

Additional findings also documented in the medical record include [include all that apply]:

  Vomiting without diarrhea

  Distended stomach

  History of similar or repeated episodes

  History of peripheral or autonomic neuropathy

  Abdominal pressure or swelling

  Treatment with Reglan (metoclopromide)

  Other (please specify

  Not applicable / None of the above

Based on your medical judgment, can you further clarify in the progress notes a specific diagnosis, if any, related to these gastrointestinal symptoms/findings and the patient’s diabetes?

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.


[Diabetic Complications]

Documentation in the medical record indicates that this patient has been diagnosed with

DIABETES and [the related complicating condition]

Additional findings include:

  Based on your medical judgment, can you further clarify in the progress notes whether or not the [related complicating condition] is due to diabetes? Other (please specify)

  Not applicable / None of the above

In responding to this request, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.