Resources Authored by: Cynthia Tang

Pneumonia vs. Aspiration Pneumonia

Case: An 85 year old male with past history of CVA and GERD is admitted from home for RLL “community acquired” pneumonia (CAP) and treated with Rocephin and Zithromax. Documentation throughout the record including discharge summary is CAP except ID consult on day 2...

Respiratory Failure Following Surgery

  Case 1: A 72 year old patient with severe COPD and history of CHF has uncomplicated bowel resection for colon cancer. He requires three days of mechanical ventilation due to decompensated heart failure and COPD with respiratory failure.  Case 2: A 55 year...

Sample Physician Query Templates

These sample physician query documents are offered solely as examples of standardized physician queries to clarify clinical documentation within the medical record. These query documents were created based on our interpretation of guidelines and may be used by...

Sepsis with Bacteremia

Case:  A 75 year old woman is admitted with UTI, fever 101.5, altered mental status, tachycardia, BUN 50 and WBC 15,000.  Admission diagnosis is “severe UTI with leukocytosis and dehydration”.  Treatment includes IV Cipro 400mg q12h and...
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