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Documentation Inconsistencies

Posted on: December 7, 2017

Physicians frequently ask CDI staff, “Why am I being queried?” A few of the main reasons include diagnosis documentation inconsistencies or conflicts with another treating physician and not linking a cause to a diagnosis present on admission.

Example 1: A patient is admitted with infiltrates and started on antibiotics; cxr impression indications “suspected pneumonia.” The attending documents pneumonia on the H&P; however, the diagnosis is not carried throughout the process notes and discharge summary. This situation creates a need for a query to find out if the condition is ruled in or ruled out or still suspected at time of discharge.

Example 2: The attending physician documents bronchitis and the pulmonary consultant documents bilateral pneumonia. A query is needed to find out if both conditions are suspected, ruled out or if the attending is in agreement with the consultant so appropriate conditions are reported for that admission.

Example 3: The patient comes in with supratherapeutic INR and GI bleed and a history of colon cancer. The patient takes Plavix, treatment is rendered to reverse the INR; however, there is no link as to what caused the GI bleed. A query is generated to find out if the Plavix contributed to the elevated INR/GI bleeding or if the GI bleeding resulted from another cause.

Dropping of a diagnosis or inconsistent documentation occurs mostly when treating physicians change schedules and a new provider comes on schedule. Part of the issue is paper progress notes in the chart, as well as electronic progress notes that are not getting reviewed. To help correct the issues, please make sure the sign off notes are being reviewed and written. Also, please contact Benny Baclawski in the physicians training office at ext. 4864 to get registered for electronic documentation and Gina Lewis, RN, at ext. 5857 for Chartwise Electronic Query registration.

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