A CDI query suggests documenting active surveillance as prostate cancer. This query is best described as which type?

A CDI query suggests documenting active surveillance as prostate cancer. This query is best described as which type?

• A. Leading and inappropriate
• B. Clarifying
• C. Correcting
• D. Compliance

Answer: (A)

In CDI, the type of query that nudges the clinician toward a specific diagnosis is called a leading query, and it’s inappropriate. Here, asking to document active surveillance as prostate cancer suggests a particular conclusion—that the patient has cancer—rather than neutrally seeking confirmation based on the chart evidence. This shifts the clinician’s documentation toward a diagnosis instead of verifying what is actually documented, which can lead to overcoding or misrepresentation. A neutral clarifying query would focus on resolving ambiguity about the documented plan and findings without pushing a particular diagnosis. It’s not simply about correcting an existing entry or about compliance rules; the problem here is the directive, leading nature of the query.

In CDI, the type of query that nudges the clinician toward a specific diagnosis is called a leading query, and it’s inappropriate. Here, asking to document active surveillance as prostate cancer suggests a particular conclusion—that the patient has cancer—rather than neutrally seeking confirmation based on the chart evidence. This shifts the clinician’s documentation toward a diagnosis instead of verifying what is actually documented, which can lead to overcoding or misrepresentation.

A neutral clarifying query would focus on resolving ambiguity about the documented plan and findings without pushing a particular diagnosis. It’s not simply about correcting an existing entry or about compliance rules; the problem here is the directive, leading nature of the query.