What should a chart reviewer do when they find a diagnosis of pregnancy without further appropriate information in an office note?

When a chart reviewer encounters a diagnosis of pregnancy lacking further appropriate information in an office note, the best course of action is to document the findings and conclude the review. This approach is aligned with the standards of HEDIS, which emphasizes accuracy and completeness in the documentation of patient records.

Documenting findings ensures that there is a clear record of what was reviewed. This is crucial because HEDIS measures rely on precise data to evaluate the quality of care provided. If the necessary details are missing, the reviewer can accurately reflect this limitation in their findings. Moreover, concluding the review at this point aligns with the process, as it would prevent unnecessary delays in reporting or processing due to inadequate documentation. This step underscores the importance of complete data for effective measurement and analysis within healthcare quality metrics.

On the other hand, options such as putting the chart aside or requesting clarification may lead to inefficiencies or delays in the review process. Scanning the office note under optional exclusion is not appropriate; the reviewer must document and conclude based on the available information rather than shifting it to a less relevant category. Therefore, effectively documenting the findings while recognizing the limits of the documentation is essential for maintaining the integrity of the review process.