Leading Queries and Compliance on CDI Pre-Charting

msumner@ripcpc.commsumner@ripcpc.com
in CDI Management

Is it considered "leading" to enter the patient assessment along with justification of the diagnosis for the Physician to add a plan to prior to the visit?

I am a CDI and the physicians are wanting more information than a typical query. We would be documenting in the note like that of a scribe for them to agree/ disagree.


Example: Pulmonary Hypertension; I27.20

(Per echo dated 6/9/25, patient with a PASP of 48 mmHg on Ace and ARB)


Thanks!

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