The query stating: “This patient received IV Azithromycin and Vasopressors; please document sepsis to justify the drug administration” is best described as which type of query?

• A. Leading query
• B. Clarifying query
• C. Correcting query
• D. Compliance query

Answer: (A)

This item tests recognizing a leading query in clinical documentation improvement. A leading query nudges the clinician to document a specific diagnosis to justify a treatment, rather than neutrally requesting information. The statement asks the physician to document sepsis in order to justify giving IV azithromycin and vasopressors, effectively steering the chart toward a sepsis diagnosis to fit the treatment provided. That direct push to document a particular diagnosis is what makes it a leading query.

If it were a clarifying query, it would ask for neutral details to confirm what is already documented or to specify the exact condition without steering toward a specific diagnosis. It’s not a correcting query, which would point out and fix an error in the current documentation, nor a compliance query, which focuses on adherence to coding rules rather than prompting a diagnosis.