Writing Queries

Queries draw attention to documentation requiring clarification or additional information. More specifically, the AHIMA standards for Ethical CDI Professionals describe some of these instances as:

conflicting, incomplete or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator).

Wording of a query is extremely important. Explain the importance of a query. What information should be included and why it is critical to not lead a physician in their response. In what ways would you insure that a query is accurate?

1 page, approx 200 words

 

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