Clinical Documentation Matters

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Confirmation of Supplemental Physicians’ Notes

Tuesday, 03 February 2009 11:45 CDMatters.com Staffer Clinical Documentation Samples

•Anaesthiologist documents “thrombophlebitis” (a CC)

•This Dx was not otherwise addressed, so could not be coded

•Attending physician later confirmed thrombophlebitis

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How would you describe your verbal query process?

	We don't verbal query at all
	We verbal query, but document the reason for the query
	We verbal query, but do not document the reason for the query
	We verbal query, but do not have a consistent policy on whether or not the reason for query is documented
	Not sure of our stance on the verbal query