CDI Physician Query For CHF
CDI Physician Query For CHF
CDI Physician Query For CHF
MRN:
Heart Failure is documented in this medical record. Specify the type and acuity of heart failure below and include the specific diagnosis in your following progress notes or addendums. Refer to the tables below for information required for specificity. Additional notes are below: ________________________________________________________________________________ ________________________________________________________________________________
Step 1: Select a specific Heart Failure Diagnosis:
Acute Systolic Heart Failure Acute on Chronic Systolic Heart Failure Chronic Systolic Heart Failure Acute Combined Systolic and Diastolic Heart Failure Acute-on-Chronic Combined Systolic and Diastolic Heart Failure Chronic Combined Systolic and Diastolic Heart Failure Other (specify diagnosis)______________________________________________________________________________ Not able to be determined Acute Diastolic Heart Failure Acute-on-Chronic Diastolic Heart Failure Chronic Diastolic Heart Failure
Step 2: Select any co-morbid or complicating conditions (possible, probable, suspected, rule out, are acceptable diagnostic terms)
Cardiomyopathy (specify type) ________________________________________ Rheumatic Heart Disease Mitral Valve Stenosis Mitral Valve Insufficiency Aortic Valve Stenosis Aortic Valve Insufficiency Acute Exacerbation of Cor Pulmonale Chronic Cor Pulmonale Hypertensive Heart Disease Hypertension Arrhythmia-Induced Heart Failure (specify Arrhythmia) ______________________________________________ Other/unable to determine:
Document any additional information as an addendum to your existing note or as a new note in the chart.
Indicate on this form if no additional information is applicable. MD Signature_____________________________________ ID#