Sample-Physician-Query-Templates-May-2018.doc - page 0...

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page 0 Sample Clinical Documentation Query Templates Table of Contents Template Topics Acute Kidney Injury Acute Tubular Necrosis Acute Blood Loss Anemia BMI < 19 BMI > 40 Chest Pain CKD Stage Debridement, Excisional Demand Ischemia with Elevated Troponins (Type 2 MI) Depression Encephalopathy – Altered Mental Status Encephalopathy v. Delirium Functional Quadriplegia GI Bleeding Heart Failure – specify type Heart Failure – specify type and acuity HIV/AIDS Hypertensive Urgency / Emergency Malnutrition Malnutrition, Severe Pancytopenia Pneumonia Specificity – HCAP Pneumonia, Aspiration Pressure Ulcer Respiratory Failure – Acute Respiratory Failure – Chronic Schizophrenia Sepsis-2 Sepsis-3 Shock Shock - Hemorrhagic Syncope TIA Cause Urosepsis Cause and effect – UTI and catheter Updated May 9, 2018
page 1 Template Topics Cause and effect – Two diagnoses Clarification of conflicting diagnosis Clinical findings without a diagnosis Clinical validation (with example for sepsis) Confirmation of a diagnosis from an interpreted report Probable/suspected cause of symptoms General query template These sample physician query documents are offered solely as examples of standardized physician queries to clarify clinical documentation within the medical record. These query documents were created based on our interpretation of guidelines and may be used by healthcare facilities at their own discretion. Pinson & Tang LLC makes no representation, guarantee or warranty with respect to these query documents, including with respect to their compliance with any relevant state, federal or other guidance. It is the sole responsibility of the healthcare facility to review and modify these examples as needed to ensure they meet their own compliance policies and standards, as well as the standards of any applicable state or federal regulatory entity. These templates are considered a copyrighted work under the United States and other copyright laws and is the property of Pinson & Tang LLC. Healthcare facilities may make archival copies and customize this template only for the limited use of their facility or organization and not for resale or public sharing. This 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 server. If any questions regarding this limited use license, contact Cynthia L. Tang for Pinson & Tang LLC: [email protected]tang.com . Recommendations for use : These query templates are designed for use as Word documents or e-messages and the content is to be edited and customized for the specific findings in each record. Suggested indicators not present in a particular case and/or multiple choice response options not supported by indicators (e.g., acute heart failure with only chronic indicators) should be deleted prior to submission to the provider. Content within brackets should be completed and deleted. Titles of each template are for reference only and should not appear on queries submitted to providers.

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