Discussion: Clinical Documentation Improvement


Clinical documentation is the basis not only for providing high quality patient care but also for showing compliance with various regulations and requirements, as well as processing healthcare reimbursement accurately and timely. When clinical documentation does not adhere to the expected level of data integrity and/or best practices, issues may emerge. Queries are one way of addressing documentation quality.  There are different ways of querying a clinician. AHIMA provides some examples at: Physician Query Examples | Journal Of AHIMA (Links to an external site.) click on this link>>https://journal.ahima.org/physician-query-examples/

Review the examples provided along with the weekly readings, and (1) discuss one of the query methods and the best scenarios for using it. Next, (2) scroll down in the Physician Query Examples page and read some of the comments to identify a relevant example or select among the examples shared in this list Week 13 Discussion Examples of documentation discrepancies.docx download  . (3) Select one of the questions asked, and (4) discuss how you would respond to that question.  

Examples of documentation discrepancies. What type of query would be best to use when reaching out to physicians for additional documentation or clarification?

1. Physician documented acute myocardial infarction but no other details were found in the record

2. The notes mention that patient has diabetes but no other details are specified. 

3. You are reviewing the record of a pregnant women. In the notes, hypertension is mentioned but no other details. 

4. In the history and physical, you read that the patient has nutritional anemia. You look into the labs an notes and you do not find anything else. 

5. The patient underwent a procedure for the suture of the forearm. The procedure notes explain what happened during the procedure, medications and tools used, but there is no mention of the size of the suture.

6. Patient was admitted with severe burns. You read in the record that they were second degree burns but that is not enough to finish the coding for the burns. 

  • The initial response must be relevant, detailed, specific, at least 250 words