Revised Physician Query policy to meet new guidelines
I am in a new CDI program and am revising our physician query policy. Looking at many ACDIS and AHIMA samples, I can't find one that uses "Guidelines for Achieving a Compliant Query Practice" as a reference. Most reference the "Managing an Effective Query Process" as the latest guidelines.
While 'Guidelines for Achieving a Compliant Query Practice' states it "...augments and where applicable supercedes prior AHIMA guidance on queries", have those organizations who have updated their policies just added escalation and query retention policies and kept the main body of their original policies unchanged?
Should more specific information addressing the various query formats (multiple choice, verbal, etc.) now need to be in the policy or be included it in a procedure? -Or is stateing staff should follow 'Guidelines..'enough?
Thanks for your help!
Deb Kent RN BSN CGRN CPHQ
Monroe Clinic
deb.kent@monroeclinic.org
608-324-1802
While 'Guidelines for Achieving a Compliant Query Practice' states it "...augments and where applicable supercedes prior AHIMA guidance on queries", have those organizations who have updated their policies just added escalation and query retention policies and kept the main body of their original policies unchanged?
Should more specific information addressing the various query formats (multiple choice, verbal, etc.) now need to be in the policy or be included it in a procedure? -Or is stateing staff should follow 'Guidelines..'enough?
Thanks for your help!
Deb Kent RN BSN CGRN CPHQ
Monroe Clinic
deb.kent@monroeclinic.org
608-324-1802
Comments
Regarding your question on how queries are retained, I would be very specific as to how that is done. Our policy indicates the verbal queries must follow the same format as written queries and that the content of the query must be retained in our electronic query tracking system. As such we document a summary of the conversation we had with the provider for verbal queries or copy and paste a copy of the electronic query into the system and add their responses when received.
What you end up doing will depend on how your process runs and the resources you have available to you, but consistency on how queries are sent, managed, and retained should be considered no matter how they are sent.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
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Saginaw MI 48602
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A 01923
I had contributed a sample policy to the ACDIS site, but haven't finished revisions with the new brief. Since I had some detail in regards to multiple choice format & other topics, I do intend to add some detail in regards to yes/no format. I also intend to add something addressing the language in the brief in regards to diagnosis not clinically supported.
I already had a policy in regards to query retention, so don't think that will change.
Definitely need to develop escalation process -- however, as a collaborative process, that will take a bit of time to work out.
Essentially, depending on what level of detail that you have in the policy strongly influences whether stating following the guidelines will be enough. IMHO, one reason to include some of the detail is for emphasis. The downside is to make sure that everyone has a common understanding (let alone read carefully) the guidelines. The other downside is only reference to follow the guidelines puts you on the hook for all of the content and doesn't allow you to more concretely interpret to your organization circumstances.
Don
Deb