RE: [MARKETING] [EXTERNAL] RE: RE:re:Superfluous queries?

robert.hodges2robert.hodges2
edited May 2016 in CDI Talk Archive
I agree with Paul that querying on some items, such as hyperlipidemia specificity when documented, is not necessarily the best use of time or resources. However whenever I see clinical indicators of a stable condition being treated, and indication for greater specificity, or an odd lab result copied into the providers note, I will query to ensure that abnormal finding is addressed. One does have to do their due diligence first to ensure it’s more than just a onetime finding though. My success story last week was an outpatient where the provider documented a GFR in the 40’s in the patients note, but no diagnosis in the assessment and plan. Rules here are that if you document an abnormal finding you must also document it’s clinical significance. After review I saw this was the patients baseline for the past 2 years so I queried and had two good things happen. First I had stage 3 CKD documented, second it was added to the patients problem list by the provider so it could be followed.



Great discussion everyone.



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



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