Reference no: EM132863756

Examples of documentation discrepancies. What type of query would be best to use when reaching out to physicians for additional documentation or clarification?

1. Physician documented acute myocardial infarction but no other details were found in the record

2. The notes mention that patient has diabetes but no other details are specified.

3. You are reviewing the record of a pregnant women. In the notes, hypertension is mentioned but no other details.

4. In the history and physical, you read that the patient has nutritional anemia. You look into the labs an notes and you do not find anything else.

5. The patient underwent a procedure for the suture of the forearm. The procedure notes explain what happened during the procedure, medications and tools used, but there is no mention of the size of the suture.

6. Patient was admitted with severe burns. You read in the record that they were second degree burns but that is not enough to finish the coding for the burns.