rule out or confirm query

cmclose@saintfrancis.comcmclose@saintfrancis.com
edited May 2016 in CDI Talk Archive
Anyone have a query form drafted to query to clarify whether a dx listed
as "rule out_____" for several days has been confirmed or ruled out? If
so, please share it.
Thanks in advance!

Claudine Hutchinson RN
Clinical Documentation Improvement Specialist
Children's Hospital at Saint Francis
Email: chutchinson@saintfrancis.com
Office: (918) 502-6603


Comments

  • jschoonhovenjschoonhoven
    edited May 2016
    This is what we use here at PeaceHealth:

    Diagnosis Confirmation Clarification

    Sepsis (for example) was documented on admission. Was Sepsis-

    -Resolving/resolved
    -Ruled out
    -Ongoing treatment
    -Other diagnosis

    Please document the current status of this diagnosis in the Progress notes and DC summary with supporting clinical findings.

    Risk factors:
    Clinical findings:
    Treatment:

    Janice

    Janice Schoonhoven RN, MSN, CCDS
    Clinical Documentation Integrity
    Manager- Oregon West Network
    541-222-5348



  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Confirmation Query Attached.

    Paul

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

  • lsipos@monument.healthlsipos@monument.health
    edited May 2016


    Pretty basic, but then, it is a pretty basic necessity to keep documenting =
    or advise of current status..


    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    719-4390 (work)
    786-2677 (cell)
    "No Limit to Better......"
    [CCDS_pin_1inch]

    "The difference between the right word and the almost right word is the dif=
    ference between lightning and the lightning bug."- Samuel "Mark Twain" Clem=
    ens
  • jschoonhovenjschoonhoven
    edited May 2016
    Yes!
    We have found over time that the cleaner and simpler we keep these the higher the likelihood a doc will engage. I believe that's a common experience :)
    Janice

  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Thank you Juli, Paul and Janice. J



    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603



  • afloydafloyd
    edited May 2016


    This is the query template that we use. So far we haven't had any problems with getting an answer with this format.

    April Floyd, RN, CCDS
    Director of CDCI
    Anderson RMC, Meridian, MS
  • cmclose@saintfrancis.comcmclose@saintfrancis.com
    edited May 2016
    Great query April. Thanks for sharing!

    Claudine Hutchinson RN
    Clinical Documentation Improvement Specialist
    Children's Hospital at Saint Francis
    Email: chutchinson@saintfrancis.com
    Office: (918) 502-6603

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