Câu 33: CDIP: Certified Documentation Integrity Practitioner

A 50-year-old with a history of stage II lung cancer is brought to the emergency department with severe dyspnea. The patient underwent the last round of chemotherapy 3 days ago. Vital signs reveal a temperature of 98.4, a heart rate of 98, a respiratory rate of 28, and a blood pressure of 124/82. O2 saturation on room air is 92%. The patient is 5’5” and weighs 98 lbs. The registered dietitian notes the patient is malnourished with BMI of 19. Chest x-ray reveals a large pleural effusion in the right lung. Thoracentesis is performed and 1000 cc serosanguinous fluid is removed. The admitting diagnosis is large right lung pleural effusion related to lung cancer stage II, documented multiple times. What post discharge query opportunity should be sent to the physician that will affect severity of illness (SOI)/risk of mortality (ROM)?

1. A. Query for malignant pleural effusion
2. B. Query for a diagnosis associated with the dietician’s finding of malnutrition — đáp án hiện tại
3. C. Query if the malignant pleural effusion is the reason for admission
4. D. Query for protein calorie malnutrition