Clinical Documentation Integrity (CDI) Specialist:

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A physician query (also known as a clinical documentation query or CDQ) is primarily generated by a Clinical Documentation Integrity (CDI) specialist or a coder.

Here's a breakdown of who generates them and why:


Most Common Originator: CDI forex database specialists are usually the primary individuals responsible for initiating physician queries.
Role: They are typically nurses (RNs) or sometimes coders with extensive clinical experience who review patient medical records concurrently (while the patient is still hospitalized or receiving care).
Why they query: Their goal is to ensure the medical record accurately and completely reflects the patient's condition, the severity of illness (SOI), risk of mortality (ROM), and the care provided. They query when documentation is:
Ambiguous: Unclear diagnoses, treatments, or causality.
Conflicting: Contradictory information within the record.
Incomplete: Missing details that would impact coding or patient care.
Nonspecific: General terms used when more precise documentation is needed (e.g., "altered mental status" vs. "encephalopathy").
Undocumented: A condition or treatment seems present but isn't explicitly stated.