Queries and the Medical Record

Unknown
in CDI Talk Archive
I have been asked to poll how many facilities and CDI programs maintain their queries and worksheets as a permanent part of their Medical Record? We currently do not, and keep our queries as well as worksheets in a separate office with the CDI's. Advise?

Comments

  • epraczepracz
    edited May 2016
    Are queries and worksheets are not part of the permanent record.

    Eileen
    OHSU


  • ssandstromssandstrom
    edited May 2016
    Our queries/worksheets are not part of the permanent record.


  • dbutlerdbutler
    edited May 2016
    I think this was one of the ACDIS polls, but might be a good time to repeat.

    It was about the 17th poll question, so was in the spring of 2008:

    Are your query forms a permanent part of the medical record, or do you remove them?
    20% They are a permanent part
    77% We remove them after the physician clarifies
    3% We don't have a policy on this

    Are you referring to concurrent queries? post discharge queries?

    Our post discharge queries are part of the medical record, concurrent queries are not but are stored / retrievable.

    Don

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



  • Unknown
    edited May 2016
    Worksheets: not a permanent part of the record but are filed on site after final coding completed (for future reference if needed)

    Queries: a permanent part of the medical record (rationale: compliance issues, continuity of the record; audit trail)


    Charlene



  • dsmith12h@aol.comdsmith12h@aol.com
    edited May 2016
    We do not keep worksheet or queries as part of the Medical Record. Once the chart is coded the sheet are routed back to CDI and entered into the CDI program.






  • Unknown
    edited May 2016
    Our queries have not been a part of the permanent record since our program's inception. However, the director of HIM recently announced that they will be sent to RAC when they request a record.



    Linnea Thennes, RN, BS, CCDS

    Clinical Documentation Specialist

    Clinical Resource Management

    Northwest Community Hospital

    847.618-3089

    lthennes@nch.org



  • melanie.halpernmelanie.halpern
    edited May 2016
    At our facility, only select retrospective queries are maintained as
    "permanent" at our community hospital.

    Thank you,
    Melanie


  • Unknown
    edited May 2016
    Our queries and worksheets are not a permanent part of the medical record.


    Kim Beard
    Clinical Documentation Specialist




  • Unknown
    edited May 2016
    Our queries are not a permanent part of the medical record. We used to
    keep them for two years, but recently were told by our manager not to
    save them any longer. We have an electronic record of all queries
    placed that is never deleted.


    Stacey Forgensi, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Erie County Medical Center
    sforgens@ecmc.edu
    Pager 642-1011


  • sbeattysbeatty
    edited May 2016
    We do not keep as part of the medical record. They are scanned as are
    the MRs but are visible only to the HI and CQM department staff. This
    allows us to have auditors hired by us to analyze for leading,
    inappropriate, etc. with the chart readily available for them to see how
    we arrived at the query. The director of HI must grant viewing
    privileges, so other auditors would not see them.

    Sandy Beatty, RN, BSN, C-CDI
    Clinical Documentation Specialist
    Columbus Regional Hospital
    Columbus, IN
    (812) 376-5652
    sbeatty@crh.org
    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens

  • kfrosch1kfrosch1
    edited May 2016
    Neither of ours are a permanent part of the medical record, they are
    maintained in the CDI office.


  • sbeattysbeatty
    edited May 2016
    What is your HI director's rationale for that? Are the queries being
    generated by coders as part of the coding process? We designed our
    program in the Clinical Quality Department, which reports to Medical
    Staff Services. We use RNs reviewing concurrently, asking for clinical
    clarity for appropriate interdisciplinary communication of the treatment
    plan to the patient care team and quality program.



    Have we received training about DRGs and coding guidelines? Absolutely.
    Are we parsing words? Perhaps-but if you get the quality of the medical
    record up to speed, then the final coding should be appropriate. I
    suppose there are two schools of thought; 1) no secrets because you've
    done nothing wrong, or 2) hand the rope to the hangman. While I believe
    we are doing nothing wrong, I have no intention of doing the RACs' job
    for them.



    Sandy Beatty, RN, BSN, C-CDI

    Clinical Documentation Specialist

    Columbus Regional Hospital

    Columbus, IN

    (812) 376-5652

    sbeatty@crh.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug." Samuel "Mark Twain"
    Clemens


  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    Our concurrent queries are not a permanent part of the medical record. After the physician responds in the record, we remove the query, enter it electronically into our tracking system, and keep the paper query in the CDI office.
    Retrospective queries sent after discharge are a permanent part of the medical record.


    Donna Fisher, CCS, CCDS
    Lead Clinical Documentation Improvement Specialist
    Health Information & Record Management
    Shands Healthcare at the University of Florida
    352-265-0680 Ext 48769
    fishdl@shands.ufl.edu



  • Unknown
    edited May 2016
    Ours concurrently are

    Carla A. Heyn, RHIT, BS

    Clinical Documentation Specialist

    Elliot Hospital

    One Elliot Way

    Manchester, NH 03103

    603-663-3452

    cheyn@Elliot-HS.org



    not part of the record, retro by HIM is permanent part of record.








  • robert.hodges2robert.hodges2
    edited May 2016
    We don't do it here. It's against VA policy to make queries or clarifications part of the medical record. It's actually too bad, because it would make the query process much easier if they did since I could do a view alert to the provider as part of the medical record.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "To climb a steep hill requires a slow pace at first."  -William Shakespeare
     

  • Unknown
    edited May 2016
    Robert,
    Is a 'view alert' part of an electronic record?


    Charlene



  • robert.hodges2robert.hodges2
    Yes they are and are tracked. The only way to do it, which one VA facility is doing, is to enter the alert and then manually delete it after 3 days. But since providers get so many view alerts, when this was discussed with them as an option, they were not keen on the idea. I'm happy with the written or telephonic query process we have in place now.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
  • Unknown
    edited May 2016
    The HIM director states it would interfere with the RAC appeal process if the RAC discovers that information was being held back in the first round.


  • theresa.s.halltheresa.s.hall
    edited May 2016
    Worksheets are not part of the permanent record.

    Queries are part of the permanent medical record.

    Theresa Hall, RHIT, ACPAR
    Director of HIM/HIPAA Privacy Officer
    East Georgia Regional Medical Center
    P. O. Box 1048
    1499 Fair Road
    Statesboro, GA 30458
    T: 912-486-1761
    F: 912-871-2388
    theresa.hall@hma.com



  • sbeattysbeatty
    edited May 2016
    Thanks for the feedback. I will forward to our HI director for consideration.


  • janrumdavisjanrumdavis
    CDI queries & worksheets are not part of the medical record. However, just like a previous responder, these forms are scanned into Chartmaxx with the medical record but only visible to HI & CDI. However, the retrospective queries left by the Coders are a permanent part of record viewable to all.

    Janice Davis, RN
    CDI Analyst
    High Point Regional Health System
  • digardskdigardsk
    edited May 2016
    The CDS worksheets and clarifications are not part of the permanent record, but are routed back to the CDSs with final coding.

    Coding retro queries are part of the permanent record.

    Kim


  • cbarnescbarnes
    edited May 2016
    We follow the same routine @ our hospital. Charlene# 2


  • michelleclynemichelleclyne
    edited May 2016
    Our CDS worksheets and queries are not a permanent part of the chart, we
    keep them in the CDS office. Coders retro queries are a permanent part
    of the chart.

    Michelle Clyne, RN, BS
    Clinical Documentation Improvement Specialist
    Good Samaritan Hospital



  • [Deleted User][Deleted User]
    There's a Benchmarking Survey on this topic from spring 2009 on the ACDIS Web site: http://www.hcpro.com/content/232429.pdf

    Also, the Physician Queries Handbook has some really valuable information on this debate. http://www.hcmarketplace.com/prod-7675/The-Physician-Queries-Handbook.html
  • [Deleted User][Deleted User]
    Here's an excerpt from the Physician Query Handbook:
    http://www.hcmarketplace.com/prod-7675/The-Physician-Queries-Handbook.html

    The Question of Query Permanence
    The issue of whether to retain written queries as a permanent part of the medical record (or whether to retain them at all) is very controversial among compliance and hospital attorneys. Some believe making them part of the medical record creates an unnecessary liability and can open RAC vulnerability.

    Others believe CDI query forms/programs should be transparent and used to defend against RAC and scrutiny from the Office of Inspector General. Work with compliance and general council to determine what works best for the hospital and then place this information in the hospital’s physician query policy. And if the query forms do not become a part of the permanent medical record, set clear policies and procedures that define query retention and address query central location, accessibility, and requests for additional information. Also, describe how to connect CDI queries to their related medical records in the event a RAC seeks additional clarification. The AHIMA physician query practice brief states:
    “Permanence and retention of the completed query form should be addressed in the healthcare entity’s policy, taking into account applicable state and quality improvement organization guidelines. The policy should specify whether the completed query would be a permanent part of the patient’s health record. If it will not be considered a permanent part of the patient’s health record (e.g., it might be considered a separate business record for the purpose of auditing, monitoring, and compliance), it is not subject to health record retention guidelines.”

    Each facility should check with its state Quality Improvement Organization (QIO) for guidelines of acceptance
  • nbrunson84nbrunson84
    Our CDS Queries are not a part of the medical record.

    However, our Queries after discharge - submitted by the final coders - are considered permanent in the medical record.

    N. Brunson,RHIA
    Clinical Documentation Specialist
    Bay Medical Center
  • cbarnescbarnes
    edited May 2016
    We do the same @ our hospital.


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