unanswered physician query
Hi, I need some guidance for document management on physician queries that are answered in the progress notes but not written on the actual query:
When a concurrent written query is posed in the medical record and is not answered on the query sheet, but is answered in the progress notes, should the written copy of the query be retained with the medical record, to show where the prompt for the new information came from ? If the answer is yes, is this unsigned/unanswered query form included when the medical record is requested for release of information?
Thank you!
Amber L. Feighner RN, BSN, CDIS
afeighner@bvhealthsystem.org
When a concurrent written query is posed in the medical record and is not answered on the query sheet, but is answered in the progress notes, should the written copy of the query be retained with the medical record, to show where the prompt for the new information came from ? If the answer is yes, is this unsigned/unanswered query form included when the medical record is requested for release of information?
Thank you!
Amber L. Feighner RN, BSN, CDIS
afeighner@bvhealthsystem.org
Comments
says" answered in progress notes 4/15/13- thank you Dr. Quick!"
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054
Carol Canipe RN, BSN, CCDS
Clinical Performance Improvement
704-834-4980
Caromont Health
Gastonia, NC 28053
"Physician documented in Medical record."
"Date __________"
"By_____________"
Our queries are part of our permanent medical record.
Dorie Douthit, RHIT,CCS
Amber L. Feighner RN BSN CDIS
Clinical Documentation Improvement Specialist
Blanchard Valley Hospital
1900 South Main Street
Findlay, Ohio 45840
419-425-5787