Certified Documentation Improvement Practitioner (CDIP) — Question 3

Patient is admitted with oliguria, pulmonary edema, and dehydration. Labs are remarkable for an elevated creatinine of 2.4, with a baseline of 1.1. Patient was hydrated for 48 hours with drop in creatinine. What would the appropriate action be?

Answer options

• A. No query is needed because the patient was dehydrated
• B. Code acute renal failure since symptoms are there and documented
• C. Query the physician to see if acute renal failure is clinically supported
• D. Query the physician to see if acute renal failure with tubular necrosis is supported

Correct answer: C

Explanation

The correct answer is C because it is essential to verify whether acute renal failure is clinically supported by the physician, given the patient's hydration response. Answer A is incorrect as it dismisses the need for further assessment; B is not ideal because symptoms alone do not confirm a diagnosis without physician input; and D, while specific, may not be necessary without first confirming acute renal failure.