verbal qeury
Good morning. Can anyone tell me their definition of a verbal query? Does it mean once you verbally asked the provider for clarification of an issue, that he then answers it in his documentation? Or, once you verbally query, IF he answers you (the CDI), that you can take that? Ok I know that sounds ridiculous, but there seems to be some issues with what is acceptable. To clarify, I have a patient with conflicting documentation. Doc #1 says sepsis on admit...never doc on again, so a query was placed and doc #2 says SEPSIS ruled out. Doc #3 comes in on the dc summary and says sepsis on admit. So, an electronic query was placed retrospectively, and the doc signed it but didn't answer it so the CDI called him and he said he already answered it on the dc summary. He really didn't because the conflict WAS his documentation. So the CDI is taking the sepsis as POA. Feelings?
Juli
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Juli
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Regional Health's mission is to provide and support health care excellence in partnership with the communities we serve.
Note: The information contained in this message, including any attachments, may be privileged, confidential, or protected from disclosure under state or federal laws . If the reader of this message is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the Sender immediately by a "reply to sender only" message and destroy all electronic or paper copies of the communication, including any attachments.
Comments
If the dc summary reaffirms an earlier statement I think it should be
taken(assuming record clinically supported the diagnosis-on admit in this
case). Maybe in final judgement they did reflect it WAS present at some
point.
I recently heard a difference of opinion on verbal queries though. People
taking credit because they verbally said yes but didn't document. In my
opinion a verbal query is verbal from CDS but requires a written response
codeable in the record to take credit for agreed.
Ann
his/her response in the record and/or Discharge summary.
Claudine Hutchinson RN (CDI)
The Children's Hospital at Saint Francis
chutchinson@saintfrancis.com
response codeable in the record to take credit for agreed.
I agree.
Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322
cell 702-204-0054