clinical-documentation-query

# Clinical Documentation Query Generate compliant physician queries to clarify clinical documentation for accurate coding, severity of illness, and risk of mortality capture. ## Overview This skill enables creation of compliant clinical documentation queries. It encompasses query identification, compliant query writing, physician engagement, and response tracking to improve documentation accuracy and coding specificity. ## Capabilities ### Query Identification - Documentation gap analysis - Clinical indicator review - Coding specificity needs - Quality measure support - DRG optimization ### Compliant Query Writing - Non-leading queries - Multiple choice formats - Open-ended questions - Clinical indicator inclusion - Evidence-based requests ### Query Types - Diagnosis clarification - Severity specification - Causation documentation - Present on admission - Clinical significance ### Response Management - Query tracking - Response monitoring - Documentation updates - Escalation procedures - Outcome analysis ## Usage Guidelines ### Query Process 1. Review clinical documentation 2. Identify opportunities 3. Gather clinical evidence 4. Draft compliant query 5. Submit to physician 6. Track response 7. Update documentation ### Compliance Requirements - Non-leading format - Clinical evidence basis - Multiple response options - Include "unable to determine" - No financial motivation mention ### Best Practices - Query concurrently when possible - Use clinical indicators - Be...