A CDI specialist reviews a record where the attending documents 'sepsis' but the blood cultures are negative and antibiotics were discontinued after 48 hours. What is the most appropriate action?
-
A
Accept the diagnosis as documented without query
-
B
Query the physician asking whether sepsis or an alternative diagnosis better reflects the clinical picture
-
C
Change the diagnosis to 'suspected infection' in the coding system
-
D
Escalate to the compliance department immediately