querying before any documentation available

Unknown

What is the general take on placing queries based only on admission lab, x-rays etc. before any physician documentation is available?

There is a discussion going on in my area that this 'is ok as it lets the physician know what you are looking'.


I have my personal opinion but would like to hear from the world of CDI.


Thanks so much.


Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center

ggoodman@virginiahospitalcenter.com

I would at least wait for the H&P and initial progress notes.
I like to give the doctor's an opportunity to document their thoughts before I Query.


Greta Goodman, CCDS
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com

kerryseekircher

Hi Charlene-
In my opinion, I'd rather first review the chart of a patient that has been admitted for at least 24-48 hours to look for any gaps in physician documentation.
Looking at it from the physicians perspective-they may feel like you aren't giving them the opportunity to do the right thing.
If I'm all caught up on work, I might pop in to a new admit to gather some clues, but leave it until the MD has an opportunity to review the same info.
Thanks,
Kerry

Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013

cmclose@saintfrancis.com

Some of our physicians dictate so their H&P and initial note may not be
available for 1-3 days (sometimes longer)~ we are hybrid still (paper
chart & EMR). I give them at least 24 hours, then query~ if I wait
longer than that, the opportunity may be lost (i.e. pt gets discharged).
I can always cancel the query if I find the answer in the transcribed
note(s) when H&P/note(s) available.

Claudine Hutchinson RN (CDI)

Hi Charlene-
In my opinion, I'd rather first review the chart of a patient that has
been admitted for at least 24-48 hours to look for any gaps in physician
documentation.
Looking at it from the physicians perspective-they may feel like you
aren't giving them the opportunity to do the right thing.
If I'm all caught up on work, I might pop in to a new admit to gather
some clues, but leave it until the MD has an opportunity to review the
same info.
Thanks,
Kerry

Kerry Seekircher, RN, CCDS, CDIP
Documentation Specialist Supervisor
Northern Westchester Hospital
400 East Main Street
Mount Kisco, NY 10549
Email: kseekircher@nwhc.net
Phone: 914-666-1243
Fax: 914-666-1013

vanessa.falkoff

I would at least wait for the H&P and initial progress notes.
I like to give the doctor's an opportunity to document their thoughts before I Query.


I agree with the H&P (unless it's late!)

Vanessa Falkoff RN
Clinical Documentation Coordinator
University Medical Center of Southern Nevada
1800 W Charleston Blvd
Las Vegas, NV
vanessa.falkoff@umcsn.com
office 702-383-7322

Compassion * Accountability * Respect * Integrity

paxneros

I like to wait for the H&P or at least 24H after admit. That's my own personal preference. However, the argument could be made that if you had CDI in the ER and were speaking w/ER & attending while patient is first here - that's before an H&P also.

Any Outpt/ER CDI folk issue queries before admission or do you give the CDS on the floor that opportunity?

Norma T. Brunson, RHIA,CDIP,CCS,CCDS

Unknown

That is a good point, if one had ED CDI staff and if you were speaking to the ED physician and getting them to document.

When I visited with our director of ED regarding documentation or lack thereof on our mortality patients I was asked if I wanted mutiny on our hands when the ED physicians rebelled against asking for thorough documentation!



Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center