clarification (query) templetes

angelamckee@uh.organgelamckee@uh.org
in CDI Talk Archive
Our facility is considering going from handwritten clarifications
to using templates. I have heard some of you have stated you have
a 100% response rate using these. Would you mind sharing some of
your templates with such a great response rate for our review?

Comments

  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    We have created template queries for AKI/CKD, CHF, anemia, debridement, malnutrition, home o2 use w/ dx, (trying to capture chronic resp failure), diabetes w/ all of the complications, decub ulcers. The physicians seem to like these, they are all check boxes and a signature.

    Amy Fenton, RN
    Clinical Documentation Specialist
    Clinical Operations Improvement
    Bronson Methodist Hospital
    601 John Street - Box 59
    Kalamazoo, MI 49007
    Office: (269) 341-8442
    Fax: (269) 341-8330
    Pager: (269) 513-3131
    E-Mail: fentona@bronsonhg.org


  • angelamckee@uh.organgelamckee@uh.org
    edited May 2016
    We are also creating templetes with check off boxes. Any chance you'd like to share an example of yours? Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga.  30901
    706-774-7836  


  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    Sure, send me your direct email and I will attached them back to you.
    Amy


  • angelamckee@uh.organgelamckee@uh.org
    edited May 2016
    Thank you! email: angelamckee@uh.org.
     Thanks again!  Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga.  30901
    706-774-7836  



  • lspryszaklspryszak
    Just a thought: some auditors frown on "check boxes". You may instead, request that they "initial" the appropriate diagnoses. From an outside perspective (think like an auditor) who's to say that the CDS or coder didn't "check" the box and only ask for a signature? I know we wouldn't actually do that (or at least, hope not) but from an "outside looking in" perspective, check boxes aren't such a great idea.
  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    I see your point. Our forms went through the same process all forms here go through. The example I will use are pre-printed order forms. Our physicians use pre-printed order forms for 99% of all admissions, surgeries, insulin drips, etc... These forms have all been reviewed by compliance and risk management. Nothing will ever be perfect, you only hope people exercise good judgement.
    Thanks,
    Amy

    Amy Fenton, RN
    Clinical Documentation Specialist
    Clinical Operations Improvement
    Bronson Methodist Hospital
    601 John Street - Box 59
    Kalamazoo, MI 49007
    Office: (269) 341-8442
    Fax: (269) 341-8330
    Pager: (269) 513-3131
    E-Mail: fentona@bronsonhg.org


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