Question

A 79 year-old female, Mrs. Carmichael, is admitted on June 15, 2015, with a right hip fracture. Her hospital stay is 3 days long. Prior to surgery, her attending physician, Dr. Fellows, orders blood work to check her hemoglobin and hematocrit levels because she is borderline anemic. The patient is cleared for surgery with a hemoglobin of 12 and hematocrit of 44 percent. Post surgery, levels are checked again with a drop in both to 8 and 32 percents, respectively. The physician orders a blood transfusion of 3 units of packed red cells. In the discharge summary, the physician only notes anemia, along with the patient’s hip fracture.

Use the attached query sample format to create your query.

In your query write a brief statement for the need of the query. (5 pts)

Provide the clinical indications for the query. (5 pts)

Ask the question, making sure that you give several options to choose from including…..unspecified, other etc. (10 pts)

Answer 1

Below given information should be present in the Query:

Name of the patient: Mrs. Carmichael

Service date: 15 June 2015

Medical record number: MR#123456

Account number: Acct. #000789

Date the query was issued along with contact information for person seeking clarification: 7/10/15 Coder-D. Marshall ext. 213

Statement of the issue: In this case, clarification of anemia. Answer should supply a note similar to the one below.

Dr. Fellows:

Based on your documentation of anemia in the record along with the clinical indicators showing a decrease in hemoglobin from 12 to 8 along with a drop in hematocrit from 44 to 32 percent, and a 3 unit packed red cells transfusion, can you further clarify the type of anemia for which the patient was being treated?

Students could leave the query open-ended or supply multiple choice answers including acute blood-loss anemia, chronic blood-loss anemia, but should also include OTHER and UNDETERMINED as options.

(AHIMA 2013, 50–53; AHIMA 2008, 83–88)

References:

AHIMA. 2013. Guidelines for achieving a compliant query practice. Journal of AHIMA 84(2):50–53.

AHIMA. 2008. Managing an effective query process. Journal of AHIMA 79(10):83–88.