When a discharge diagnosis of septicemia is not documented by the physician, but laboratory tests and treatment align with septicemia, how should the physician be requested to document this condition?

• A. An addendum to the chart should be written.
• B. Document septicemia in the discharge summary.
• C. Rewrite the history and physical.
• D. Code septicemia based on lab results.

Answer: (A)

The key idea is that coding relies on a diagnosis that the physician has documented. When there’s strong clinical evidence—lab results and treatment—that septicemia is present or highly likely, the chart should explicitly reflect that diagnosis, and the way to do this is to have the physician add an addendum to the chart. An addendum allows the physician to document septicemia after reviewing the evidence without altering the original note inappropriately, and it creates an auditable, accurate record that supports coding.

This approach keeps the medical record truthful and complete. If you coded septicemia based only on labs or treatment, you’d be labeling a diagnosis that isn’t officially documented by the clinician, which isn’t appropriate. Rewriting the history and physical isn’t the proper route, and simply including septicemia in the discharge summary without the physician’s documented confirmation can lead to inaccuracies. So the correct step is requesting an addendum to document the condition as recognized by the physician.