Sample Clinical Documentation Query Templates …

1 Sample Clinical Documentation Query TemplatesTable of ContentsTemplateTopicsAcute Kidney InjuryAcute Tubular NecrosisAcute Blood Loss AnemiaBMI < 19 BMI>40 Chest PainCKD StageDebridement, ExcisionalDemand IschemiawithElevated Troponins (Type 2 MI)DepressionEncephalopathy Altered Mental StatusEncephalopathy v. DeliriumFunctional QuadriplegiaGI BleedingHeart Failure specify typeHeart Failure specify type and acuityHIV/AIDSH ypertensive Urgency / EmergencyMalnutritionMalnutrition, SeverePancytopeniaPneumonia Specificity HCAPP neumonia, AspirationPressure UlcerRespiratory Failure AcuteRespiratory Failure ChronicSchizophreniaSepsis-2 Sepsis-3 ShockShock-HemorrhagicSyncopeTIA CauseUrosepsisProbable/suspected cause of symptomsCause and effect Twodiagnosespage1 UpdatedFebruary 6, 2018 TemplateTopicsClarification of conflicting diagnosisConfirmation of a diagnosis from an interpreted reportClinical findings without a diagnosisClinical validationGeneral querytemplateThese Sample physician Query documents are offered solely as examples of standardizedphysician queries to clarify Clinical Documentation within the medical record.

2 These querydocuments were created based on our interpretation ofguidelinesand may be used byhealthcare facilities at their own & Tang LLCmakes no representation, guarantee or warranty with respect to thesequery documents, including with respect to their compliance with any relevant state, federalor other guidance. It is the sole responsibility of the healthcare facility to review and modifythese examples as needed to ensure they meet their own compliance policies and standards, aswell as the standards of any applicable state or federal regulatory areconsidered a copyrighted work under the UnitedStates and othercopyright lawsandisthe property of Pinson & facilities may make archival copies and customize this template only for thelimited use oftheir facility or organization and not for resale or public template and any customized or modified version of this template may NOT be sold,distributed, published to an online gallery, hosted on a website, or placed on a public any questions regarding this limited use license, contact Cynthia L.

3 Tangfor Pinson & for use: These Query Templates are designed for use as Word documentsor e-messages and the content is to be edited and customized for the specific findings in eachrecord. Suggested indicators not present in a particular case and/or multiple choice responseoptions not supported by indicators ( , acute heart failure with only chronic indicators)should be deleted prior to submission to the provider. Content within brackets should becompletedanddeleted. Titles of each template are for reference only and should not appearon queries submitted to providers. 2018 Pinson & Tang,LLC. All Rights 6, 2018 Acute Kidney InjuryDocumentation in the medical record indicates that this patient has been admitted with ordiagnosed as following lab is also documented in the medical record:[include criteriathat apply] Creatinine on admission = BaselineCreatinine (if known): Correction of serum creatinine from ____ to _____ following rehydration Urine output:Based on your medical judgment, can you please clarify in the progress notes thediagnosisassociated withthese findingssuch as: Acute Kidney Injury Acute on Chronic Renal Failure Chronic Kidney Disease (Stage, if known) Other(please specify) None of the above/Not applicableIn responding to this request, pleaseexercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!

4 Page3 UpdatedFebruary 6, 2018 Acute Tubular Necrosis(ATN) Documentation in the medical record indicates that this patient has been admitted with ordiagnosed as havingACUTEKIDNEY following is also documented in themedical record: Creatinine levels [list all and dates] FENa = Urine sodium concentration = Urine output of _____over___ hours IV contrast Medication[if potentially neurotoxic]: Other:Based on your medical judgment, can you further clarify in the progress notesconfirmedorsuspectedunderlying causefor this patient s conditionsuch as: Acute Tubular Necrosis Acute Cortical Necrosis Acute Glomerulonephritis Pre-Renal AcuteKidney Injury Other condition:(please specify) None of the above/Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!page4 UpdatedFebruary 6, 2018 Acute Blood Loss AnemiaDocumentation in the medical record indicatesthe following: Diagnosis ofAnemia[include type] Drop in Hct/Hgb fromto Bloodtransfusion of xxxunits GI Bleeding[or other hemorrhage] Other:Based on your medical judgment, can you further clarify in the progress notesthe diagnosisassociated with these findingssuch as: Acute blood loss anemia Acute hemorrhagic anemia Chronic blood loss anemia Acute on chronic blood loss anemia Iron deficiency anemia Otheranemia:(please specify) None of the above/ Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!

5 Page5 UpdatedFebruary 6, 2018 BMI < 19 Documentation in the medical record indicates that this patient has a:BMI =The following is also documented in the medical record [if pertinent to below diagnoses]:Based on your medical judgment, can you further clarify in the progress notesthe diagnosisassociated with these findingssuch as: Underweight Cachexia Emaciation Malnutrition Undernutrition Anorexia Other condition (please specify) None of the above/ Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!page6 UpdatedFebruary 6, 2018 BMI > 40 Documentation in the medical record indicates that this patient has:BMI =The following is also documented in the medical record [if pertinent to below diagnoses]:Based on your medical judgment, can you further clarify in the progress notesthe diagnosisassociated with these findingsinthe progress notes such as: Overweight Obesity Morbid obesity Othercondition (please specify) None of the above/ Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!

6 Page7 UpdatedFebruary 6, 2018 Chest PainBased on the Documentation in the medical record,this patient was admittedwithCHEST information inthe medical records includes:Based on your medical judgment, can you further clarify in the progress notesthemost likelyor suspectedunderlying causefor this conditionsuch as[includeonly those thatmayapply]: Coronary artery disease GERD/reflux Esophagitis oresophagealspasm Pleurisy Costochondritis Chest wall / musculoskeletal pain Gastritis Hiatal hernia Anxiety Hyperventilation syndrome Biliary colic Peptic Ulcer Other cause(please specify) None of the above/ not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!page8 UpdatedFebruary 6, 2018 CKD StageBased on the Clinical information documented inthe medical record, this patient has beendiagnosed withChronic KidneyDisease / in the medical record also indicates: GFR =Based on your medical judgment, can you further clarify in the progress notesthe appropriatestage of CKD?

7 National Kidney Foundation stages ofChronic Kidney Disease (CKD):Stage 1: GFR > 90 Stage 2: GFR 60-89 Stage 3: GFR 30-59 Stage 4: GFR 15-29 Stage 5: GFR < 15 ESRD: Need for dialysisIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!page9 UpdatedFebruary 6, 2018 Debridement ExcisionalBased on the Documentation in the medical record, this patient has undergoneWOUND CAREand/orWOUND on your medical judgment, can you further clarify in the progress notesthetype ofwound debridement: Excisionaldebridement (use of a scalpel/blade to cut away tissue) Non-excisionaldebridement (chemical,scrubbing,trimming with scissors) Other debridement(please specify) None of the above /Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!

8 Page10 UpdatedFebruary 6, 2018 Demand IschemiawithElevated Troponins(Type 2 MI) Documentation in the medical record indicates that this patient has been admitted with ordiagnosed as having following is also documented in the medical record[includeonly thosethat apply]: Serial troponin levels [list all] = Associated conditions: [include potential causes, , severe anemia, sepsis,hypotension or shock, rapid tachycardia,hypertensive crisis] Treatment: [any treatment or management of associated conditions] EKG showing: History of CAD or MIBased on your medical judgment, can you further clarifyin the progress noteswhich, if any,of the following thiscondition is intended to indicate: Type 2 MI Type 1 MI (NSTEMI) Demand ischemia only Unstable angina Other, please specify: None of the above/ Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!

9 Page11 UpdatedFebruary 6, 2018 DepressionDocumentation in the medical record indicates that this patient has been admitted with ordiagnosed as having following is also documented in the medical record: Psychiatricconsult Medication change from _____ to _____ Symptoms: Behavior: Other:Based on your medical judgment, can you further clarify in the progress notes the status ofthis patient s DEPRESSION:Type and Severity: Major (MDD) Simple Situational Endogenous Bipolar Mild Moderate Severe Other (please specify) None of the above/Not applicableIn responding to this request, please exercise your independent professional judgment. Thefact that a question is asked does not imply that any particulardiagnosisis desired you!page12 UpdatedFebruary 6, 2018 Encephalopathy Altered Mental StatusDocumentation in the medical record indicates that this patient has been diagnosed as havingthe symptom ofALTERED MENTAL findings also documented inthe medical record: [includeall that apply] Feverof ____ Infection: [type] Dehydration Electrolyte Imbalance: Sepsis Hypoxemia Renal / Hepatic Failure Drug toxicity or adverse effect: Abnormal lab tests: Other findings:Based on your medical judgment, can you further clarify in the progress notesifthesefindingsassociated with altered mental status aredue to a definiteor suspectedunderlyingneurologic causesuchas.

10 Metabolic Encephalopathy Toxic Encephalopathy Altered mental status without encephalopathy Other condition (please specify) None of the above/ Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not imply that any particulardiagnosisis desired you!page13 UpdatedFebruary 6, 2018 Encephalopathyvs. DeliriumDocumentation in the medical record indicates that this patient has been diagnosed as havingthe symptom findings also documented in the medical record:[include all that apply] Fever of _____ Infection: [type] Dehydration Electrolyte Imbalance: Sepsis Hypoxemia Renal / Hepatic Failure Drug toxicity or adverse effect: Abnormal lab tests: Other findings:Based on your medical judgment, can you further clarify in the progress notesifany of thefollowarea definite orsuspectedcause of delirium: Metabolic Encephalopathy Toxic Encephalopathy An underlying psychiatric disorder (please specify) Another condition (please specify) Delirium without an underlying cause None of the above / Not applicableIn responding to this request, please exercise your independent professional that a question is asked does not implythat any particulardiagnosisis desired you!