Conflicting documentation exists where admission notes state no evidence of heart failure, but the discharge summary states congestive heart failure present on admission. Which clinician should clarify this discrepancy?

• A. Attending physician
• B. CDI specialist
• C. Nurse manager
• D. Medical records clerk

Answer: (A)

Resolving documentation discrepancies rests with the clinician who is responsible for the patient’s care. The attending physician reviews the full chart—the admission note, progress notes, tests, and the discharge summary—and determines the accurate status of conditions like heart failure on admission. If the records conflict, the attending physician clarifies the diagnosis, possibly adding a clarifying note or updating the problem list so the chart reflects what truly occurred. This ensures correct coding, billing, and quality reporting. A CDI specialist can request clarification to improve documentation, but the final clinical determination comes from the attending physician. Nurses and records clerks handle coordination and file management, not the clinical reconciliation.