clarifications as part of audits

tiffany_susantiffany_susan
in CDI Talk Archive
Could anyone who has the experience of having your concurrent clarifications included in a request for medical records from a payor, please offer there insight/perspective of the process and the outcome? I have heard rumors that some facilities have had to submit these clarifications to auditors.

Comments

  • stacy.vaughnstacy.vaughn
    edited May 2016

    Typically, the request from payors comes after the patient has been
    discharged. In that case, if my query remains on the chart then it is a
    permanent form on the Medical record. The physician ultimately has dated
    and signed the query to add or clarify a diagnosis not documented in the
    medical record.

    My actual worksheets I use for data collection is not a part of the
    medical record and ours is pulled off and routed back to me at discharge.

    Stacy





  • dogdog
    My queries remain on the chart, but they are not part of the permanent medical record. Physicians are required to document any changes in response to my query in the progress notes or in a dictation. We would not release any queries as part of a request for records.

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
    (602) 532-1117 (desk); (602) 532-1918 (mobile)
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