A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath.

AHIMA CDIP Question Answer

A 50-year-old male patient was admitted with complaint of 3-day history of shortness of breath. Vital signs: BP 165/90, P 90, T 99.9.F, O2 sat 95% on room air. Patient

has history of asthma, chronic obstructive pulmonary disease (COPD), and hypertension (HTN). His medicines are Albuterol and Norvasc. CXR showed chronic lung

disease and left lower lobe infiltrate. Labs: WBC 9.5 with 65% segs. Physician documented that patient has asthma flair and admitted with decompensated COPD,

ordered IV steroids, O2 at 2L/min via nasal cannula, Albuterol inhalers 4x per day, and Clindamycin. Patient improved and was discharged 3 days later. Which action

would have the highest impact on the patient's severity of illness (SOI) and risk of mortality (ROM)?

Query the physician to clarify if CXR result means patient has pneumonia.

Query the physician to clarify for type of COPD such as severe asthma.

Query the physician to clarify for clinical significance of the CXR results.

Query the physician to clarify if patient has acute COPD exacerbation.