by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.
When we talk about clarity, we might be referring to an instance where a diagnosis is stated without documentation of cause or suspected cause or there is no clinical validation. We might need clarification of a potential cause and effect relationship that directly impacts how a coder interprets that relationship. A coder may also need more clarity as to whether a condition is present on admission (POA) and that determination can’t be made based on current documentation.
Example of Clarity issue:
- Patient is admitted with pneumonia. The admitting H&P exam reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 F; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.
- Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators?
- In this patient admitted with pneumonia, the admitting history and physical examination reveals the following: WBC 14,000, Respiratory rate 24, Temperature 102° F, Heart rate 120, Hypotension , Altered mental status, IV antibiotic administration, IV fluid resuscitation.
- Please document the condition and the causative organism (if known) in the medical record.
In this example, there is certainly a question as to whether this pneumonia patient might be considered to have sepsis. The query issue is simply the fact that any specific documentation of sepsis is not found anywhere in the record.
The query is just a restatement of the known facts and then raises a legitimate question that calls out for better clarity.
Documentation Consistency and an Example of how a Good Physician Query is Developed
- AHIMA Practice Brief: Managing an Effective Query Process, 2008
- AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
- AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010