Documentation of queries

swalz

Does your CDI program have a policy on how you document paper versus verbal queries in your system? I do not mean for making the query itself; I mean for documenting that a query was made and then documenting the response or lack of response. If so, please elaborate specifically what your policy is on making and documenting a verbal query. Thank you, in advance.

robert.hodges2

We document all queries the same way be they verbal, written or via email. We just indicate if they are verbal vs. email in our tracking software.

Policy is that verbal queries must follow the same format as written/emailed queries.

Hope this helps and Happy CDI Week!

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
Clinical Documentation Improvement Week
September 16-22 2012

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katysuegood@gmail.com

We document a query as "written" or "verbal" in our electronic software system (CDR2). We then enter the response (or lack thereof) for both types (if verbal, we do not state that it was responded to unless answered in the medical record).
I know some programs actually write out the verbal query and keep record of it this way, we do not do this as of yet.

I hope this answers your questions

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

don.cdi.rn@gmail.com

I've shared my policies in the F&T library. Essentially, verbal queries are documented with as much detail as possible (the same as expected with written queries) as far as content, options, etc. They are written up to reflect that they are recording a verbal conversation that took place.

The verbal query essentially has the same needs as a written query -- non-leading, present options if not open ended, clinical facts to support the question, etc.

Unfortunately, with our software, we have no way to capture these discretely from written queries.

Don