Review the complete inpatient chart provided for this assignment. Include in your review:
Emergency Room notes
ECHO results
Chest x-ray findings
Providers SOAP note
Provider progress notes
Vital signs flowsheets
Lab results
2. Complete the Clinical Documentation Audit form that is included with the patient chart. If you feel that a section of the audit form is not applicable based on the documentation, check the box in that section that indicates N/A.
3. Do you feel, based on patient documentation, that a provider query is required? If so, create a physician query. Please note, queries do the following:
Pose a question to physicians to obtain additional clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedures codes as well as improve patient care, clarifies significant reportable condition, procedure or other reportable data;
Patient documentation is used to evaluate the adequacy and appropriateness of quality of care, validate medical necessity, and support reimbursement. It needs to be as complete and accurate as possible.
In creating your query please be careful to:
Use precise language
Identify documented clinical findings that you are citing
Always include basic query components
Be specific enough to elicit a diagnostic opinion (neither leading nor vague)
Be respectful
Do not sound presumptive, prodding or as if leading to an assumption
In your query, you can create a patient name and identifying information as well as the provider’s name you are querying. Use the current date in your query. The date of admission for the patient will be November 22, 2021, and the discharge date will be November 27, 2021.
Grading Rubric:
|
Criteria/Scale |
Exemplary |
Meets Expectations |
Inadequate |
Total Points |
|
Structure |
10 |
|||
|
Coding Query Grammar/Mechanics |
Free of spelling, punctuation and grammatical errors. |
Most spelling, punctuation, and grammar correct allowing reader to progress through information. Some errors remain. |
Spelling, punctuation, and grammatical errors create distraction, making reading difficult. Errors are frequent. |
|
|
Coding Query Question substance |
Query subject was correct. Query language was appropriate. Includes all points detailed in assignment. |
Query subject was correct. Query language was appropriate. Some points remain missing or misplaced. |
Query subject lacked substance. It shows some understanding of what information is missing. Does not include all points detailed in instructions. Serious errors. |
10 |
|
CDI Audit Form |
Audit form was completed correctly based on patient documentation. No errors. |
Audit form was completed correctly based on patient documentation. One to three errors. |
Audit form was completed based on patient documentation. Four plus errors. |
10 |
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