query process

kshumpertkshumpert
edited May 2016 in CDI Talk Archive
Our current process is to utilize the same query for CDI and coders. Does anyone else follow suit? The idea was for continuity of the query process.

Kathy Shumpert, RN, BSN

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

[cid:image001.jpg@01CB3975.B55D2B50] Proofread carefully to see if you any words out. ~Author Unknown


Comments

  • NormaBNormaB
    edited May 2016
    Yes we use the same queries for both. We modified them slightly to allow physicians to document on the discharged queries. They are a permanent part of the record.

    For CDI we did not include an area for documentation as we encourage the physicians to document within the record. Our CDI queries are not a permanent part of the record.


  • davisd2davisd2
    We use a different worksheet/query that we place on the chart while patient is in house it is not a permanent part of the record. We ask the MDs to mark if they agree and also document in progress notes. The coders use a completely different form. We did not want the physicians to confuse the 2 different types of queries.

    Denise Davis RN
    Clinical Documentation Specialist
    Quality Management
    Sonora Regional Medical Center
    1000 Greenley RD Sonora Ca 95370
    209-536-3290
    davisd2@ah.org
  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    Our coders do not query. We handle all queries.


  • robert.hodges2robert.hodges2
    Our policy says that we all do it the same way and use the same forms, but in practice I'm the only one using forms.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
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