Verbal query

laura.reurink@avera.orglaura.reurink@avera.org
in CDI Talk Archive
I am interested in knowing how your teams utilize verbal queries.
Do you use them? If so, how and when? How do you capture the information?

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    We do, though not nearly as much as written queries. Our written queries are part of the permanent medical record so we find that they are the best way to ensure that the response actually makes it into the record. Also, our MD's have made it clear that they prefer not to be interrupted for verbal clarification unless we really feel it is something best handled face-to-face. Additionally, our MD's are not available very much on the floor anymore anyways. As discussed in other threads, this shift happened when we went to a fully electronic record.
    When we do query verbally, the CDS is to document the verbal query in our CDI software. This way, it is tracked just like other queries. This year's query brief recommends that documentation include the actual language used by the CDI and be in similar format to a paper/electronic query.

    Hope that helps!

    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
  • rmhosler1rmhosler1
    edited May 2016
    I agree, credit is taken for a verbal query if the doctor also documents
    it in the record.

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