Verbal queries and placing response in problem list

cynthia.a.goewey

We have a group of physicians proposing a new query process for us. This is their proposed process: CDS is to page MD and discuss query (won't be sending any written queries). After discussion and response recieved CDS is to then place diagnosis in Problem List. MD will then have to sign/agree to formalize this diagnosis in the problem list.

Thoughts? Has anyone done this or had discussions with compliance/legal about this type of process? What about all verbal queries? I have reviewed the responses earlier under the discussion of populating the problem list.

Thanks,
Cindy

robert.hodges2

I do a large number of Verbal queries, again as a provider preference. Our policy is that the verbal query must follow the same format as the written/emailed query. Also, and this is in accordance with our policy and the new AHIMA/ACDIS query practice brief, the content of your discussion with verbal queries must be documented and recorded. As such, I always document what was discussed with the provider along with the providers response in the health record to the query.



The only part that makes me nervous about your process is that you add the new diagnosis to the problem list for the provider to sign. I don't do that here. It's up to the provider to add the diagnosis and to document to support it.



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



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katysuegood@gmail.com

I agree. With verbal queries, they need to be documented by the CDS in the same format as a written query. The adding the dx to the problem list makes me nervous. I am curious to see what you come up with. There have been discussions about us (CDI) adding dx to the problem list as well (though only after it has been documented) and I have concerns about it. I think it’s interesting that the providers prefer verbal queries. Our providers have asked not to be approached with verbal queries except in unique situations. They find it disruptive. I have a sneaky suspicion that they would/will complain regardless of our approach ;-)

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

rmhosler1

Cindy:
We talked about this also, but only for the paper problem list in the
chart. I believe as long as the physician signs it )showing agreement)
you are ok. Otherwise, I would say no. I am excited for you they
actually want you to page them. However, I also realize the challenges
with that too.

Good luck!!




Mary A. Hosler RN, MSN CDS
Mary A Hosler, RN, MSN CDS
Alumnus CCRN
McLaren Bay Region
1900 Columbus Ave.
Bay City, Michigan 48708
(989) 891-8072
mary.hosler@mclaren.org

"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug."- Samuel "Mark
Twain" Clemens

cynthia.a.goewey

Hi Katy,
The providers proposing this are hospitalists so they are always around. Not sure that it will work with surgeons or the specialists who are also in clinic.
Cindy