Provider Responses

megan.bartonmegan.barton
in CDI Talk Archive
If you write a query to a provider and an alternate provider later documents what you were looking for (without seeing the query) do you: Give credit to the documenting provider? Give credit for your query?

We currently mark these as "agreed" by the documenting provider but I'm not sure if we can really take credit.

Thanks!
Megan Barton RN, BSN
Manager CDI - Mercy East St. Louis
314-251-6192

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    I track these and see if the queried provider addresses it as well. Good job to the person who did the documentation without a query, but it's important in my mind to follow up anyway to see if the one you talked to responded. I have had them call me and say that someone else addressed it, and I do count that as a response. If they don't do anything, then it counts as abandoned.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    “Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We recently had this conversation. I addressed it with leadership because although I want to make our program "look good", I don’t think it's accurate to mark it as answered. Additionally, it warps the data so we are less able to determine which providers are answering and which aren’t.
    However, leadership disagreed and just wants it marked as answered if the necessary data ends up in the record. Whether it's as a response to our direct query or not and regardless of who actually answers it. So, that’s what I'm doing.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    At this time, I simply mark as 'responded' and give credit to the Attending. Honestly, I know this is not the most accurate methodology, but for a number of practical reasons (we are a very large site with sometimes dozens of clinicians actively involved in the care of one patient), it would be too tedious and time-consuming to be more exact.



    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • judithbatesjudithbates
    edited May 2016
    I agree Paul...

    Judi Bates RN, BSN, CCDS
    Our Lady of Lourdes Medical Center
    CDI Specialist
    856-757-3161
    Beeper 66x2906
  • robert.hodges2robert.hodges2
    In my home grown data base I mark them with a "D" for documented by another provider, and have a response of "No" for the queried provider. That is also how I report them in my metrics. The queried provider will yet a "Yes" for response if they respond saying it was documented by X and they have nothing to add.

    Robert

    Robert S. Hodges, BSN, MSN, RN, CCDS
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • paxnerospaxneros
    edited May 2016
    Hmmm... I don't know if we have ever encountered this before! That's an
    interesting dilemma! I'm guessing you do not leave your queries until
    discharge? Some do - some don't. We leave our queries until they are
    answered or the patient is discharged (they are removed at that point and
    returned).

    Sometimes they are answered by another provider who reads the query. We
    give credit to that physician and count it as an answered query. It's
    removed at that time. We still have physicians who are reluctant to answer
    queries. So, any documentation from other providers who are more savvy at
    documentation is greatly appreciated!

    Norma T. Brunson, RHIA, CDIP, CCDS
  • megan.bartonmegan.barton
    edited May 2016
    Norma,

    It IS interesting! :) We have an electronic record and the queries go through the providers' mail in EPIC. No other provider can see the query. I audit the query responses to see what the impact is and wanted to see if others faced this situation.

    Thanks!
    Megan

    Megan Barton RN, BSN
    Manager Clinical Documentation Improvement
    Health Information Management-Mercy East
    Ph: 314-251-6192 / Fx: 314-251-3982
  • paxnerospaxneros
    edited May 2016
    Okay, that's why- you have an Electronic query. We are still hybrid and able to leave paper queries for all providers to see.

    In that case I would almost put that query in a separate category altogether - or not claim it as documentation acquired through CDI efforts. I wouldn't give it to the attending if he wasn't the one who documented the information requested. I wouldn't count it as answered either.

    Perhaps you could collect it as "physicians who are practicing good documentation" and submit them to administration for a kudos of some kind. Recognition might encourage others to be more diligent.

    I'm going to keep this filed away as we extend the reach of our electronic record. I'm sure we will see this in the future!

    NBrunson, RHIA,CDIP,CCDS
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