Citing/Sourcing Clinical Indicators within a Query
Hello,
I am aware that within the AHIMA/ACDIS Query practice brief 2022 it states " All relevant diagnoses, lab findings, diagnostic studies, procedures, etc. which illuminate the need for a query should be noted and cited as to the location within the medical record." I am confused by the writers choice of using the verb "should". Should can be ambiguous, implying a recommended action or advisory rather than a mandatory requirement. I understand best practice, however is it required for every clinical indicator regardless of the volume it's noted within the medical record have a date/citation/source? For example, a diagnosis is documented several different places throughout the Medical Record, is dating the location of each instance required for query compliance?
Thank you very much for helping to clarify.