Q&A: Systemwide clinical definitions on queries
Q: Do your query templates ever include the clinical criteria needed to establish the diagnosis being queried when multiple choice diagnoses are offered? For example, on a sepsis query, does the query itself include the institutional criteria for establishing the diagnosis or is this a potentially leading query? Do your validation queries contain institutional diagnostic criteria when the diagnosis has been established but the reviewer is seeking validation?
Response #1: My understanding is you can add the definitions/guidelines into the query. You cannot add a new diagnosis if it is not in the record note, as that is considered leading. Also diagnosing is outside a nurse’s scope and clinicians may feel offended to have their judgment questioned.
Here is an example from one of our queries:
In your clinical opinion, please further clarify, after study, the patient’s condition of atrial fibrillation.
Based on your medical judgment, please indicate if any of the following diagnoses are appropriate for this patient.
[ ] Paroxysmal atrial fibrillation
[ ] Persistent atrial fibrillation
[ ] Permanent or chronic atrial fibrillation
[ ] Other ______________
| Type | Definition |
| Paroxysmal atrial fibrillation | Recurrent (>1 episode >30 seconds in duration; episodes generally last ≤ 7 days). AF that terminates spontaneously within 7 days. |
| Persistent atrial fibrillation | AF that is sustained usually >7 days or lasts <7 day, but necessitates pharmacologic or electrical cardioversion. |
| Permanent atrial fibrillation | AF refractory to cardioversion or accepted as final rhythm. A decision has been made not to pursue restoration of sinus rhythm by any means, including catheter or surgical ablation. |
Response #2: We always include clinical criteria in our queries at our institution. We provide criteria at the top of the query as part of a clarification rather than directly tying it to a diagnosis option. Validation queries can cite institutional criteria explicitly to ensure alignment without being leading.
Scenario: A patient has an elevated white blood cell count, fever, and documented tachycardia. Sepsis is documented inconsistently in progress notes but not included in the final diagnosis. The institution uses SIRS criteria for diagnosing sepsis.
Subject: Clarification of Diagnosis
Dear Dr. …,
The medical record indicates the following clinical findings during this encounter:
- White blood cell count: 14,500/mm³ (elevated)
- Heart rate: 112 beats per minute (tachycardia)
- Temperature: 101.2°F (fever)
Additionally, documentation mentions (state any supporting evidence, such as “suspected infection” or “elevated lactate levels”).
To ensure accurate documentation and coding, can you please clarify if the patient’s condition was due to:
- Sepsis (please specify the suspected or confirmed source of infection)
- Systemic inflammatory response syndrome (SIRS) due to [infection/non-infectious cause]
- Another condition (please specify)
- Unable to determine
Note: If sepsis is confirmed, it is recommended to document the suspected or confirmed source of infection, as well as any associated organ dysfunction. Please use your clinical judgment based on the patient’s presentation.
Thank you for your attention to this matter. If you need additional assistance, feel free to reach out to the CDI team.
Sincerely, (CDI specialist name, title, and contact information)
Response #3: We are in the process of including clinical criteria in our query templates to establish the diagnosis being queried. We do not consider the information leading, as we are just presenting the clinical criteria, and the provider can review and assess the information to make their decision regarding what diagnosis is most appropriate for the patient.
Response #4: Our queries do not directly include our institutional criteria. We do have a systemwide clinical definition link in the query templates for: ABLA, acute encephalopathy, acute kidney injury (AKI), acute respiratory failure, malnutrition, sepsis, and type two myocardial infarction (MI). If the provider clicks on the link in the query template, it will direct them to the systemwide clinical definition on our SharePoint Page.
Response #5: We always include clinical criteria in all our queries. We have it broken down by already documented, signs and symptoms, risk factors and treatment. It is not required that each section be completed, but often they are. Clinical validation queries contain facility clinical definitions for the diagnosis. So far, we have developed criteria for MI, AKI, acute respiratory failure. Our facility utilizes Sepsis-2 criteria, but we do not include it on the clinical validation query.
Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.