Queries
W are revising our CDI policy; while we are rather clear as to leading and non-leading queries, there is a gray area (a difference of opinion) as when to query.
An example:
Patient admitted through ED on 11/26/12; arrives to floor 11/27/12, 0130;
CDIS reviewing chart on 11/27/12 a.m.
No H&P available in EMR or paper chart; Labs available, Cr+ 1.5; glucose 431.
History of DM on ED record; no mention of CKD.
Is it appropriate for CDIS to query physician for Acute or Chronic Renal Failure and Uncontrolled DM?
I understand "institutions" differ on policy and training, but could this be "introducing" a diagnosis and /or be leading?
A question also raised was, should there be a 24 hr "allowance" for the physician to dictate or write the H&P?
Hope you can help!!
Colleen M. Nolan R.N.
CDI Specialist
Quality Management
Phone: 440-816-6398
cnolan@swgeneral.com
[cid:imagea30d77.gif@161393ad.6f4d4844]
Southwest General - HEALTH is our passion, QUALITY is our focus, COMPASSION is our way
18697 Bagley Road | Middleburg Heights, Ohio | 44130-3497 | Tel: 440-816-8000 | www.swgeneral.com
An example:
Patient admitted through ED on 11/26/12; arrives to floor 11/27/12, 0130;
CDIS reviewing chart on 11/27/12 a.m.
No H&P available in EMR or paper chart; Labs available, Cr+ 1.5; glucose 431.
History of DM on ED record; no mention of CKD.
Is it appropriate for CDIS to query physician for Acute or Chronic Renal Failure and Uncontrolled DM?
I understand "institutions" differ on policy and training, but could this be "introducing" a diagnosis and /or be leading?
A question also raised was, should there be a 24 hr "allowance" for the physician to dictate or write the H&P?
Hope you can help!!
Colleen M. Nolan R.N.
CDI Specialist
Quality Management
Phone: 440-816-6398
cnolan@swgeneral.com
[cid:imagea30d77.gif@161393ad.6f4d4844]
Southwest General - HEALTH is our passion, QUALITY is our focus, COMPASSION is our way
18697 Bagley Road | Middleburg Heights, Ohio | 44130-3497 | Tel: 440-816-8000 | www.swgeneral.com