Whenever physician's notes are ______, HIM must query the physician?

The situation where a health information management (HIM) team must query a physician about their notes arises whenever there are issues such as incompleteness, ambiguity, or contradictions in the documentation. Each of these factors can impact the interpretation, quality, and legal standing of a patient's medical record.

When notes are incomplete, vital information may be missing, which could affect clinical decision-making and patient care. HIM professionals must seek clarification from the physician to ensure the record accurately reflects the patient's healthcare history.

If physician's notes are ambiguous, it can lead to misunderstandings regarding diagnoses, treatments, or patient conditions. Queries help clarify these points, ensuring that everyone involved in patient care understands the physician's intentions and the clinical context.

In cases where documentation is contradictory, there may be conflicting information within the notes that can complicate care. HIM must address these inconsistencies through queries to uphold the integrity of the medical record and avoid potential errors in patient treatment.

In summary, it is essential for HIM to query physicians whenever documentation has these issues to maintain accurate, complete, and clear medical records, ensuring the highest standard of patient care and compliance with regulations. Therefore, all the conditions listed necessitate a query to the physician, making it critical to select the comprehensive answer that