Query based on patient's statement
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.
Comments
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?
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.