Documentation with no clinical support

Good Morning!

I would like to pose a question to the group...
What do you do when you see a diagnosis written with no clinical support?
For example acute respiratory failure may be documented but you don't see any low O2 sats, no treatment given other than a few liters of O2, etc.
Do you query the physician and ask them to please provide clinical indicators to support the diagnosis?
And if so do you have a query form for this that you might be willing to share?

Thank you!
Greta

Greta Goodman, CCDS
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com

Comments

  • edited May 2016

    I have attached a query we use specifically for these instances.

    Julie Cruz RN, CDS

    Clinical Documentation Specialist
    St. Joseph Health
    2700 Dolbeer St
    Eureka, CA 95501
    wk: 707-445-8121 ext. 7550
    cell: 707-267-0973


  • I think ours looks like everyone else's. I agree with Robert, Yes we should=
    query. However, I also don't think we query as often as we should...

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

Sign In or Register to comment.