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Health record number

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Objective
After completing this assignment, students will be able to construct an appropriate physician query for documentation discrepancies.
Resources
Chapter 6, “Physician Query Procedures” section page 126 of the Revenue Cycle Management Best Practices textbook
Instructions
1. After reading the articles in the resource section above, write an effective query for the following clinical scenario:
The surgeon documents in their operative report that a biopsy of the colon was performed without further specification of the exact site. The exact site of the colon biopsy is not documented anywhere in the medical record.
2. The written query must use the most appropriate format (for example open-ended) as discussed in the reading.
3.The written query must also include the elements below per the reading (use a fictitious name, account number, etc. if not provided in the scenario).
Patient Name
Admission date and/or date of service
Health record number
Account Number
Date query initiated
Name and contact information of the individual initiating the query
Statement of the issue in the form of a question along with clinical indicators specified in the clinical scenario. For example, the history and physical states urosepsis, the lab reported WBC of 14,400.
Directions on where or how the physician should document their response
An area where the physician can sign and date their response to the query

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