3M vs. JA Thomas with EPIC-help please

fentona@bronsonhg.orgfentona@bronsonhg.org
in CDI Talk Archive
We are currently using EPIC and have been for 1.5 years. We currently abstract and send our queries in EPIC. We use 3MDOCMS for data/CDI program support. Another facility that we recently aquired uses JA Thomas for data/ CDI program support. Our facility is looking to consolidate vendors. We met with JA Thomas last week and I have a question for everyone regarding some information provided... I am wondering about leading queries. The example given was: Patient presents with AMS, elevated lipase level, elevated LFT's, Their suggested query was: Does this patient have hepatic encephalopathy? I was under the understanding that you cannot present a new diagnosis? That you can clarify and offer s/sx, but cannot offer a diagnosis that has not been presented already by the physician?
Thanks so much, any help is appreciated.

Amy Fenton, R.N.
Clinical Documentation Specialist
Bronson Hospital
Quality and Safety
601 John Street
Box 59
Kalamazoo, MI 49007
Phone 269-341-8442
Fax 269-341-8330
E mail fentona@bronsonhg.org

Comments

  • sharon.colesharon.cole
    edited May 2016
    Hi Amy,
    We had that exact same problem with Allscripts queries - they asked if the clinical data represented a specific diagnosis. We ended up writing our own queries with non-leading questions. As a nurse speaking to a physician that would be considered appropriate communication, but as a CDI Specialist speaking to a physician, it is considered inappropriate to "lead" that way.
    Sharon Cole, RN, CCDS
    254-751-4256
    sharon.cole@phn-waco.org

  • sannwoodysannwoody
    Please review the new AHIMA/ACDIS query brief. It is on the ACDIS site. You can offer choicese of dx not already documented but have to have clinical evidence to support it and offer choices of other and clinically unable to determine
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