Reference no: EM133699010

Question

In conducting a qualitative review, the clinical documentation specialist sees that patient came in for fever and pneumonia and on the 2nd day of admission developed sepsis However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? Note that sepsis was present on admission. Query the physician to determine if the condition was present on admission. Note the condition as unknown on admission. Note the condition as not present on admission.