Wiki "Leading" Queries and Documentation Guidelines

[LargoFLSunshine]

Is it considered "leading" to enter the patient assessment along with justification of the diagnosis for the Physician to add a plan to prior to the visit?
I am a CDI and the physicians are wanting more information than a typical query. We would be documenting in the note like that of a scribe for them to agree/ disagree.

Example: Pulmonary Hypertension; I27.20
(Per echo dated 6/9/25, patient with a PASP of 48 mmHg on Ace and ARB)

Thanks!

 

[sls314]

Is it considered "leading" to enter the patient assessment along with justification of the diagnosis for the Physician to add a plan to prior to the visit?
I am a CDI and the physicians are wanting more information than a typical query. We would be documenting in the note like that of a scribe for them to agree/ disagree.

Example: Pulmonary Hypertension; I27.20
(Per echo dated 6/9/25, patient with a PASP of 48 mmHg on Ace and ARB)

Thanks!

"We would be documenting in the note like that of a scribe for them to agree/ disagree."

I would absolutely not do that.

 

[toria11]

I agree with the above, I would not do that either. Maybe you could explore the use of customizable templates that the providers could use instead.