At the Association of Clinical Documentation Improvement Specialists (ACDIS), questions on physician queries are never few and far between. Although AHIMA has published a couple briefs on the topic over the last decade, questions have still remained about how to implement a compliant and effective query process.
Editor's note: Medical Records Briefing (MRB) catches up this month with Monica Pappas, RHIA, president of MPA Consulting in Long Beach, Calif., and an MRB advisory board member, to discuss physician queries.
Editor's note: The commentary in this article was originally presented in the HCPro, Inc., February 7 audio conference, "The Pediatric Medical Record: Opportunities for Documentation Improvement." Learn more about the audio conference at http://tinyurl.com/bbh9yl5.
A death row inmate develops a lump near his breast and is sent to a local hospital for an examination. The physician wants to perform medical imaging to diagnose the lump, but correctional staff won't remove his shackles. It's impossible to perform the test wearing restraints. He returns to the prison without a diagnosis.
Patients who require nutrition support after discharge can be at risk for readmission if their condition isn't managed carefully. They may experience complications from underfeeding, dehydration, and electrolyte imbalances, says Noreen Luszcz, RD, MBA, CNSC, Walgreens Infusion Services (WIS) nutrition program director.
