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Tip: Asking the right question can lead to the right answer

CDI Strategies, November 15, 2007

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(Editor's note: Due to an editing error, the below tip in the November 15, 2007 CDI Strategies contained some misprints. We apologize and are repeating the corrected tip in full.)

The way a clinical documentation improvement (CDI) specialist phrases a query is just as important, if not more so, than the information for which he or she is asking, says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, an independent consultant located in Maryville, TN. Consider the following clinical scenario:

A patient undergoes a laparoscopic appendectomy. The physician discovers a retroperitoneal hematoma with extensive bleeding, and opts to switch from a laparoscopic to an open procedure.

After opening up the patient, the physician notes that the patient becomes hypotensive. The physician administers saline and two units of packed red blood cells. The patient stops bleeding and the physician resumes surgery.

The CDI specialist, noting that it sounds like the patient may have hypovolemic shock, leaves a brief query asking, "Is this hypovolemic shock," but receives no answer. Why? The query itself is too blunt and sounds accusatory. "It (non-answer) may be because the physician is embarrassed that he missed the diagnosis," Krauss says.

A better query to ask is, "As noted in the operative note in the record of patient X, does this information meet your clinical definition of hypovolemic or hemorrhagic shock with acute blood loss anemia, or is this simply hypotension with blood loss?"

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