GI Bleed POA Query
I'm a new CDI with a question about POA Query for GI Bleed. I have a patient who was admitted for Sepsis and found to have a DVT and PE an was on anticoagulation of Lovenox, aspirin and Brilenta . His Hgb was slowly dropping about .5 each day and then a sharp drop of 2pts after day 6. He had emergent EGD that found : Large ulcer in the duodenal bulb with two visible vessels, one of which was actively bleeding and a second small white based ulcer in the duodenal bulb.
I am sending a query for POA Status. Is the following wording consider leading or is it acceptable to use for things like GI Bleed and CHF Exacerbations etc. ?
Documentation clarification is requested to accurately reflect patient severity. Being the attending physician, please clarify if this patient’s GI Bleed was developing and was present on admission (POA) or not, or if you are unable to determine.
Based on the above information, was this condition present on admission? Please place your cursor inside the bracket and place an “x” next to your selection(s).
[ ] Yes [ ] No
[ ] Clinically undetermined