query process in CERNER as permanent past of the legal record

sbeattysbeatty
in CDI Talk Archive
I would like to have any CERNER users who also use 3M's CDIS product to contact me regarding queries. We have just made the decision to have queries become a legal part of the record. We need to determine the best process to implement this between CDIS and CERNER. If we allow the MDs to answer directly on the query, this also allows them the capability to amend the verbiage of the query as well. If they can edit a document in CERNER, it seems they can edit any part of that document. That leaves me feeling a little uneasy. I don't want anyone else to be able to revise words attributed to me. We're anxious to know what others are doing.

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We do not use the 3M product. But, we are going live with electronic queries in CERNER soon (currently we are paper but they are a part of the permanent record). We are building the queries in PowerNote. We have templates made with required fields (check boxes, free text, etc). We fill out our portion, send to the MD, he responds and signs. It functions similar to a co-sign for a mid-level.

    I don’t know if that helps at all....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404

  • ddouthitddouthit
    edited May 2016
    Katy,

    Will they be able to place a checkmark for their response or will they be required to type out a response?

    Dorie Douthit, RHIT,CCS
    CDI Program/HIM


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    They will not have to type it.
    Its technically no longer a check-box. The options are listed and then they highlight the one they choose (just click on it). If they choose "other" a free-text box appears and they can type in their answer.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Office: 928.214.3864
    Cell: 928.814.9404


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