Query based on patient's statement

Anna_Rozhkovskaya

Patient with SSC who continued to complain of her generalized SS crisis pain, treated with Dilaudid. Per patient, she had Hx of necrosis, however no x-rays were done during this stay, nor physician documentation to support the validation of avascular necrosis.

Can we base the query just on patient's statement?

You input would be greatly appreciated.

Anna Rozhkovskaya, CDI manager.

Anna_Rozhkovskaya

Patient with SSC who continued to complain of her generalized SS crisis pain, treated with Dilaudid. Per patient, she had Hx of necrosis, however no x-rays were done during this stay, nor physician documentation to support the validation of avascular necrosis.

Can we base the query just on patient's statement?

drew.siegel205

I would not query on the basis of the patient's statement because it does not appear that the necrosis (if present) was being evaluated, monitored, or treated and would not likely meet criteria for a secondary diagnosis.
 I would look for information such as physical therapy evaluation, nursing notes, or other indication that a musculoskeletal condition was being addressed and use that as support for a query.