Documentation Consistency and an Example of How a Good Physician Query is Developed

Documentation Consistency and an Example of How a Good Physician Query is Developed


by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.

Consistency
We talk about consistency with regards to either differing diagnoses between two or more providers or we might also be referring to documentation of clinical indicators, diagnostic tests, and treatment but no related “after study” condition documented.

Example of Consistency Issue:
A patient is admitted with chest pain radiating through to his middle back. The provider orders multiple tests to rule out cardiac diagnoses which are all ruled out. On day 2 of the stay, the provider orders the head of the bed to be raised, no coffee or fatty foods, and a 20 mg dose of omeprazole daily. On day 4, the patient’s symptoms subside and he is discharged home. There is no diagnosis documented by the provider.

Consistency query:

  • Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators?
  • This patient was admitted with chest pain radiating through to his back. Cardiac testing was performed and a cardiac condition was ruled out based on the documentation. The patient received a no fat, no coffee diet with orders to elevate the head of the bed and 20 mg of omeprazole daily.
  • Please document the condition and the causative organism (if known) in the medical record.

In this instance, the documentation seems to vacillate between chest pain of a cardiac nature versus chest pain due to some other cause. You need a diagnostic statement to code and you have several that seem to be inconsistent with each other.

This patient seems to have an “after study” diagnosis that falls in the realm of indigestion/gastritis but that is not stated. The goal of a query here is to get a consistent diagnosis documented that identifies what condition meets the “after study” principal diagnosis definition.

The query is just a restatement of the known facts and asks for a consistent interpretation of what is documented.

Next:
Documentation Precision and an Example of How a Good Physician Query is Developed

 

References:

  • 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

About the Author

Chris Richards, RHIA, CCS
Chris joined Barry Libman Inc. as a Senior Associate in 2014 after 27 years with Masspro, the Massachusetts Quality Improvement Organization (QIO). Chris’s areas of expertise include health information administration, case management, quality improvement, hospital payment oversight, and documentation education initiatives. He has a comprehensive understanding of the Federal Medicare program rules and regulations, as well as extensive experience ensuring that clinical coding and DRG assignment result in accurate provider reimbursement. A graduate of Hobart College, he received a postgraduate Bachelor of Science in Health Information Administration from Northeastern University.

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