A CDI template query stem asserts “the patient has acute respiratory failure” as fact, then asks the provider to confirm type—although respiratory failure is the contested issue. What compliance problem does this create?
Select an answer to reveal the explanation.
Short Explanation
If the question already declares the diagnosis true, the “clarification” is theater. Stems must stay neutral on the contested point. Asserting it as fact is leading.
Full Explanation
Query stems must not treat the diagnosis under dispute as an established fact. Assertive template language that presupposes the condition leads the provider and fails neutrality review. Even approved-looking templates can be noncompliant if misapplied to a contested diagnosis. Compliance evaluation includes stem wording, not only the option list.