The discharge includes a diagnosed uterine cancer based on pathology, while the hysterectomy note mentions a uterine mass. The query described here is an example of which type of CDI query?

The discharge includes a diagnosed uterine cancer based on pathology, while the hysterectomy note mentions a uterine mass. The query described here is an example of which type of CDI query?

• A. Leading
• B. Clarifying
• C. Confirming
• D. Informational

Answer: (A)

Leading queries are those that push a specific diagnosis by stating it in the query and asking the clinician to confirm it. In this scenario, the discharge already presents a cancer diagnosis based on pathology, while the hysterectomy note only mentions a mass. A query that says something like “Please confirm uterine cancer per pathology” or otherwise implies that cancer is established directs the clinician toward endorsing that diagnosis, rather than simply clarifying the discrepancy. That imposition is the hallmark of a leading query. The appropriate approach would be to ask for clarification about the conflicting documentation without asserting the diagnosis, such as requesting confirmation of whether the final diagnosis is uterine cancer or a benign uterine mass based on the pathology report. This keeps the query neutral and avoids biasing the chart.

Leading queries are those that push a specific diagnosis by stating it in the query and asking the clinician to confirm it. In this scenario, the discharge already presents a cancer diagnosis based on pathology, while the hysterectomy note only mentions a mass. A query that says something like “Please confirm uterine cancer per pathology” or otherwise implies that cancer is established directs the clinician toward endorsing that diagnosis, rather than simply clarifying the discrepancy. That imposition is the hallmark of a leading query. The appropriate approach would be to ask for clarification about the conflicting documentation without asserting the diagnosis, such as requesting confirmation of whether the final diagnosis is uterine cancer or a benign uterine mass based on the pathology report. This keeps the query neutral and avoids biasing the chart.