Title: Midterm Quiz
Course: HIM 3620 - TAACCCT Grant > Section: Module 7 - Midterm

Q: A patient is admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.

Query: The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas cultured from the blood. Are you treating for sepsis?

Is this open-ended query leading or Nonleading?
- Leading
- Non-leading
A: Leading

Q: Please read the documentation and query and assess appropriateness of querry,

A patient is admitted with pneumonia. The admitting H&P examination reveals WBC of 14,000; a respiratory rate of 24; a temperature of 102 degrees; heart rate of 120; hypotension; and altered mental status. The patient is administered an IV antibiotic and IV fluid resuscitation.

Query: Based on your clinical judgment, can you provide a diagnosis that represents the below-listed clinical indicators?

In this patient admitted with pneumonia, the admitting history and physical examination reveals the following:

- WBC 14,000
- Respiratory rate 24
- Temperature 102° F
- Heart rate 120
- Hypotension
- Altered mental status
- IV antibiotic administration
- IV fluid resuscitation

Please document the condition and the causative organism (if known) in the medical record.

Is this an example of  a leading or nonleading query?
- leading
- Nonleading
A: Nonleading

Q: Review the clinical scenario and answer the question regarding type of query

Clinical Scenario: A patient is admitted with cellulitis around a recent operative wound site, and only cellulitis is documented without any relationship to the recent surgical procedure.

Query: Is the cellulitis due to or the result of the surgical procedure? Please document your response in the health record or below.

Yes _____________

No ______________

Other ___________

Clinically Undetermined ______________

Name: ___________________          Date:__________
- leading yes/no query
- non leading yes/no query
A: non leading yes/no query

Q: The following query was found in a patient's health record.  Which of the answer best appies to this query?

Dr. Smith-this patient was seen in the ER two weeks prior to this admission for pneumonia and prescribed antibiotics.  She is admitted today for fluid overload due to chronic congestive heart failure.  Please document the pneumonia in your progress notes.
- This is a leading query
- This is a yes/no query
- This is an appropriate query
- This query brings in information not documented within the chart and is inappropriate
A: This query brings in information not documented within the chart and is inappropriate

Q: The following query was found in a patient's health record.  Which of the answers best applies to this query?

Dr. Smith- this patient was admitted through the Emergency room with multi-system trauma.  Duraing surgery she was transfused with 5 units of packed red blood cells, and fresh frozen plasma.  Her laboratory work indicates a 10 point drop in her hematocrit levels, and you documented anemia in her post-operative progressive note.  On day two she was transfused with additional units of pack red blood cells.  Please document the type of anemia you are referring to.
- This is a leading query
- This query brings in information not documented within the chart and is inappropriate
- This is a yes/no query
- This is an appropriate query
A: This is an appropriate query

Q: Is the following query appropriate or inappropriate, justify your answer.

Clinical Scenario: In the ED, a foley catheter was inserted for the patient with dysuria and elevated WBCs that was removed two days after admission. The cultures were positive for E.coli and the progress note reflect a catheter associated urinary tract infection (CAUTI) and this was coded. Quality has requested review of the HAC condition to ensure it should be coded as it does not meet the CDC definition for CAUTI.

Query: The quality department has indicated that your documented diagnosis of CAUTI does not meet the CDC definition which impacts the Hospital Acquired condition statistics for your profile as well as the hospital. Does your patient have a catheter associated urinary tract infection?

Yes ____________

No ______________

Other ___________

Clinically Undetermined _________________

Name: ___________________          Date:__________
Feedback: This query is inappropriate as it explains the impact of the addition or removal of the diagnosis for the physician and hospital profiles. This query questions the physician’s clinical judgment which may be more appropriate in an escalation policy and/or physician education regarding the CDC definition of CAUTI.

Q: Write a multiple-choice or open-ended query for the following scenario:

Clinical scenario: A patient is admitted with an acute gastrointestinal bleed, and the hemoglobin drops from 12 g/dL to 7.5 g/dL and two units of packed red blood cells are transfused. The physician documents anemia in the final discharge statement.

Query: In this patient admitted with a gastrointestinal bleed and who underwent a blood transfusion after a drop in the hemoglobin from 12 g/DL on admission to 7.5 g /dL, can your documentation of anemia be further specified as an acute blood loss anemia? Please document your response in the health record or below accompanied by clinical substantiation.

Yes ______________

No ______________

Other ____________

Clinically Undetermined ____________

Name: ___________________          Date:__________

Rationale: In this example, a yes/no query is not appropriate for specifying the type of anemia. A multiple-choice or open-ended query is a better option. Write a more appropriate multiple-choice or open-ended query.