The attached sample queries were donated Audrey G. Howard, RHIA, AHIMA-Approved ICD-10-CM/PCS Trainer, and Cheryl Manchenton, RN, BSN, 3M Consulting, adapted from the 2012 HCPro Inc., audio conference “Inpatient Postoperative Complications: Resolve Your Facility’s Documentation and Coding...

Cynthia Prayzner at Southcoast Health System in New Bedford, Mass., offers this sample altered mental status query form which asks physicians to identify the chronicity of the diagnosis providing additional specificity not on the query form but in the medical record's progress note. 

This sample query regarding establishing cause and effect relationships between diagnoses was donated by Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity, at SutterHealth in San Francisco, Calif.

This document exlains how to query for encephalopathy when ''acute delirium'' is well documented in the chart. It was provided by Cindy Prayzner at South Coast.
 

This document is a formal approach to documenting postoperative respiratory failure. It is provided by Paul Evans, RHIA, CCS, CCS-P, CCDS, of Sutter Health in San Francisco

This form can be used to query physicians for additional information for HIV patients.

This documentation clarification form can be used to clarify relationship between the diagnosis and a surgical procedure. It is provided by Katy Good, RN, BSN, CCDS, CCS, Clinical Documentation Program Coordinator, AHIMA Approved ICD-10CM/PCS Trainer, of Flagstaff Medical Center in Flagstaff, AZ...

This documentation clarification form can be used to determine whether a patient's past medical history is relative to the current diagnosis and a current problem affecting care and treatment during the current hospitalization. It is provided by Katy Good, RN, BSN, CCDS, CCS, Clinical...

This PowerPoint presentation includes information on pediatric malnutrition, including definitions, classifications, and an assessment scoring sheet. It is provided by Dr. Robert Gold of Atlanta.

This query form is the standard VHA query form for clarification of depression. It was submitted by Robert Hodges, BSN, MSN RN, CCDS, Clinical Documentation Improvement Specialist at the Aleda E. Lutz VA Medical Center in Saginaw, MI.

Pages