RE: [MARKETING] [EXTERNAL] RE: RE:re:Superfluous queries?
I appreciate your comments but still respectfully disagree. This is another indication where one program has a different focus or philosophy than another. It doesn’t mean either is wrong, just a different way of looking at things.
Personally I see the goal of CDI to ensure that the health record is complete, accurate, that it addresses all issues which may impact severity of illness and/or risk of mortality, and supports continuity of care. In addition, the record needs to support the resources expended by nursing and all other services involved in the care of the patient. As such I find very few queries "excessive". Please note though I do my due diligence in ensuring that I have reviewed the entire record before I send a query. If it is documented in a place it can be captured by coding then there is no reason to query, but if not then I don' t hesitate. Some examples include:
1. A dietician documenting "malnutrition with severe nutritional risk" after an assessment and oral supplements ordered.
2. Nursing documenting incontinence or an immobile patient requiring frequent care or turning, or even behavioral disturbances in patients.
3. Medications or treatments ordered, but no corresponding diagnosis to indicate what is being treated with those medications in the record by the ordering provider.
Again, this is just my philosophy and since I work for a health system with a fully integrated health record, it is something I most assuredly must keep in mind.
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
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
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley
Personally I see the goal of CDI to ensure that the health record is complete, accurate, that it addresses all issues which may impact severity of illness and/or risk of mortality, and supports continuity of care. In addition, the record needs to support the resources expended by nursing and all other services involved in the care of the patient. As such I find very few queries "excessive". Please note though I do my due diligence in ensuring that I have reviewed the entire record before I send a query. If it is documented in a place it can be captured by coding then there is no reason to query, but if not then I don' t hesitate. Some examples include:
1. A dietician documenting "malnutrition with severe nutritional risk" after an assessment and oral supplements ordered.
2. Nursing documenting incontinence or an immobile patient requiring frequent care or turning, or even behavioral disturbances in patients.
3. Medications or treatments ordered, but no corresponding diagnosis to indicate what is being treated with those medications in the record by the ordering provider.
Again, this is just my philosophy and since I work for a health system with a fully integrated health record, it is something I most assuredly must keep in mind.
Robert
Robert S. Hodges, MSN, BSN, RN, CCDS
Clinical Documentation Improvement Specialist
VHA CDI Council Member
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
VA Core Values: Integrity, Commitment, Advocacy, Respect, Excellence (“I CARE”)
VA Core Characteristics: Trustworthy, Accessible, Quality, Innovative, Agile, Integrated
"We are dealing with Veterans, not procedures; With their problems, not ours." --General Omar Bradley