ACDIS Poll results -- Auditing Queries

dbutlerdbutler
edited May 2016 in CDI Talk Archive
Does anyone else have a high level of concern about these poll results??

52% report conducting NO AUDITS for compliance??

(attached is from an Excell file I maintain of all of the ACDIS polls -- useful & fun tool)

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com




Comments

  • robert.hodges2robert.hodges2
    Perhaps a question may be how many use template queries approved by their compliance departments and since they only used approved queries do not do auditing for that reason? I know I have all my template queries approved by Compliance before implementing them and SOP is that verbal queries must follow the templates.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • wfreemanwfreeman
    I am concerned, but can understand how it happens. Our senior leadership
    is very supportive and gives us all the resources we need. I have talked
    with many who are understaffed, no office space in which to work, and no
    support from physicians and senior leaders. My coding supervisor and I
    both do random audits monthly and quarterly audits from outside sources.
    It is very beneficial and keeps everyone on the up and up. Honestly, I
    think there will come a time when CMS, Joint Commission, HFAP, and DNV
    will begin to regulate CDI and set standards that effect accreditation.
    Maybe that will help facilities put resources toward doing necessary
    things like auditing queries.

    Bill Freeman, RN, BSN
    Supervisor of CDMP
  • dbutlerdbutler
    edited May 2016
    Good point.
    An additional response could have been: "We don't do compliance audits of queries because we only use template queries that are pre-approved by compliance &/or legal."

    Having some sort of check and balance would seem to me to be important in the establishment and advancement of CDI as a profession.
    Not to mention of course the possible liability and exposure issues.

    Don


  • sbeattysbeatty
    edited May 2016
    I do. We are part of the 52%, in my opinion. We have an annual extensive
    outside audit done that includes query auditing for compliance. We
    formerly used a consultancy company, but have discontinued that
    contract. That's why I asked about second level reviews. I've been
    asking about this internally for a couple of years now.

    Is there anything else I can do for you?
    Clinical Quality Management would like your feedback on our ability to
    meet your needs. Please complete a satisfaction survey for our
    department.

    Sandy Beatty, RN, BSN, C-CDI
    Clinical Documentation Specialist
    Columbus Regional Hospital
    Columbus, IN
    (812) 376-5652
    sbeatty@crh.org

    "Obstacles are those frightful things you see when you take your eyes
    off the goal." Hannah More

  • sbeattysbeatty
    edited May 2016
    This is part of my rationale for diagnosis-specific queries which are approved by the medical staff as well as the compliance officer, who happens to be director of HI.

    Is there anything else I can do for you?
    Clinical Quality Management would like your feedback on our ability to meet your needs. Please complete a satisfaction survey for our department.

    Sandy Beatty, RN, BSN, C-CDI
    Clinical Documentation Specialist
    Columbus Regional Hospital
    Columbus, IN
    (812) 376-5652
    sbeatty@crh.org

    "Obstacles are those frightful things you see when you take your eyes off the goal." Hannah More


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