Citing/Sourcing Clinical Indicators within a Query
Good Afternoon,
I have a question regarding my understanding of the 2022 ACDIS/AHIMA query brief. The brief 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 author's use of the verb "should". Should can be ambiguous, implying a recommended action or advisory rather than a mandatory requirement. I understand it may be best practice, however, is it required for every clinical indicator to have a date/citation/source attached regardless of the volume documented within the record? For example, if a diagnosis of Sepsis is noted within multiple notes, consults etc, is it required to include the date and location of each instance for the query to be compliant? or are there times when a date/citation is not necessary?
Thank you for helping to clarify this.