Query for MD illegibility?

mannb1mannb1
in CDI Talk Archive
Hi, all,
I'm wondering if anyone has a query they'd be willing to share that addresses MD illegibility? I have been told that if 2 coders can't read a chart/note, it's considered illegible, but does anyone have a query specific to this (likely) wide-spread issue - for those of us not lucky enough to have EMR as yet?

Thanks very much,
Becky Mann, RN, CDS
Sutter Solano Medical Center
Vallejo, CA
mannb1@sutterhealth.org

Comments

  • kshumpertkshumpert
    edited May 2016
    I leave a generic query for them stating that the progress note is illegible and to please clarify or dictate a clarification of existing documentation note. One of my functions with the RAC team is to clarify all illegible documentation before the medical record is mailed to the RAC-I think I heard someone giggle when I was assigned the task:) We don't use two people to confirm it is illegible. Illegible is illegible and a potential safety concern for our patients. An outside auditor will not spend much time attempting to read a note or order. The fact is that almost physician, midlevel, or nurse I speak to about legibility knows their penmanship is terrible and really don't fight me. Our chief medical director is completely on board with this (she has excellent penmanship) I have had physicians ask me if I can read so-and-so's handwriting. Good luck!!



    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Clinical Documentation Improvement Specialist
    Howard Regional Health System
    Office 765-864-8754
    Cell phone 765-432-3961
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela



  • sharon.colesharon.cole
    edited May 2016
    We don't have a query, but I have written a query that said:
    "The above information may have been addressed but I am unable to read the note. Please clarify patient's diagnoses list."

    The physician was embarrassed, he laughed and apologized.

    Our MR/UR committee devised a post card that addressed illegibility and mailed it to each and every physician as well as posting it all over the hospital. I'll see if I am allowed to share it and if so, will post it.



    Sharon Cole, RN, CCDS
    Providence Health Center
    Case Management Dept
    254.751.4256
    srcole@phn-waco.org


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