Clinical validation
need help with formulating query. Have diagnosis of acute on chronic diastolic heart failure listed throughout chart. I do have supporting documentation for the diagnosis chest x-ray, BNP. The problem I am having with this chart is patient was never treated with any diuretics PO or IV.
We have formatted queries that we use at our facility and I am not able to find one that I feel fits this.
I looked at the clinical validation, ruled in/out diagnosis.
Any help would be appreciated.
We have formatted queries that we use at our facility and I am not able to find one that I feel fits this.
I looked at the clinical validation, ruled in/out diagnosis.
Any help would be appreciated.
Comments
I would use Clarification of Clinical Findings or Clinical Validity template stating: The medical record consistently documents the diagnosis of acute on chronic diastolic heart failure with chest x-ray showing ______ and BNP of ____. (also list any additional findings of rales, edema, weight gain, pleural effusion, pulmonary edema, DOE, …)
Question to Physician: Please clarify the treatment provided for your patient’s acute on chronic diastolic heart failure.