Documentation Clarification Form
Date:
Time:
Dear Dr.
In responding to this query, please exercise your independent professional judgment. Please be advised that coding regulations for
inpatient admissions allow the physician to document presumptive/possible diagnosis. The fact that a question is asked does not imply
that any particular answer is desired or expected. Thank you for your clarification on this documentation.
.
The patient has undergone (Surgical Procedure) and the medical record documents the following:
(Potential complication: state findings/condition/dx perioperative or postoperative)
Based on your medical judgment and review of the clinical indicators,
Could you please clarify relationship between the above diagnosis and the
surgical procedure?




Diagnosis was likely directly related to the surgical procedure
Diagnosis was likely unrelated to the surgical procedure
Other __________________________________
Unable to determine
PHYSICIAN SIGNATURE
DATE
This form is a permanent part of the medical record
Thank you!
X
Katy Good, RN, Documentation Specialist, Extension 13864, Email: Kathryn.good@nahealth.com
HIM Coder
For Medical Questions: Dr. Mark Foster, Cell: 928-607-2797
Flagstaff Medical Center
1200 North Beaver Street • Flagstaff, Arizona 86001
DIAGNOSIS CLARIFICATION FORM
Updated 04/18/2012