GI Bleed POA Query
Hello All,
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
Comments
To clarify the DVT and PE were found after admission and the Lovenox, asprin and Brilenta were all started "after" admission? Or was the patient on those medications on admission?
Given the Hgb was dropping from admission it's a valid question to ask if the bleed was POA or not. I would probably ask the question like this:
"On day one patient Hgb dropped xxx followed by additional daily drops of xxx until day six when a xxx drop occurred. Patient underwent emergent EGD which identified a duodenal ulcer with actively bleeding vessel. In your professional opinion was the bleeding vessel present on admission or did it develop after admission?". Give him the choices of PRESENT ON ADMISSION, NOT PRESENT ON ADMISSION, UNABLE TO DETERMINE.
I don't think your query is leading as you worded it.
Erik
I think your "was developing" could just be omitted and the way you have it or alternate wording would be fine. I do not like - yes, no questions.even if legal, I prefer to write choices, when ever possible. One benefit of writing out choices, is that it educates, the providers can often get the point of your question, and you give them a clear explanation that they can use, that is not what you may be hoping will be the answer.
Example- please clarify POA status of DVT-
DVT present on admission,
DVT, asymptomatic but worsened, POA,
DVT not POA, developed during the stay, despite anticoagulation
Unable to determine if DVT POA, but suspect POA despite anticoagulation
O,
UATD