Câu 44: CDIP: Certified Documentation Integrity Practitioner

A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

1. A. That the blood loss was not clinically significant
2. B. The associated diagnosis and the clinical rationale in the progress notes — đáp án hiện tại
3. C. The associated diagnosis directly on the query form
4. D. A cause-and-effect relationship between anemia and the underlying cause