Queries/doc-reminders
I would like to find out how everyone manages their queries after the patient is discharged. We are not paperless and our queries are hand-written and stay with the medical record until the patient is discharged. As of now, the doc-reminders are sent back to us after the record has been coded. While coding the record, the coder will comment as to if the query has been addressed (if it was not addressed prior to the patient being discharged). We then enter in the response data into Soft Med and I run monthly reports for response rates. If the query is answered prior to the patient discharge, the response to the query is entered into Soft Med at time of review by the Doc Specialist.
We are now changing the process in Medical Information so that all discharged patient's medical records are scanned into the computer prior to coding. The coders will not see our doc-reminders to make notations on them. We will not get the hard copy of the doc-reminder back from the coder.
Can anyone tell me their process for the management of queries made concurrently but not answered until time of discharge? Do you keep hard copies of your doc-reminders or do they become part of the permanent record?
My department conducts 2500-2700 reviews a month and writes 500-900 queries each month. We query for every diagnosis that documentation is not clear and concise-- not just the ones that will increase re-imbursement. We want our medical record to stand against all outside auditors and we review all medical records for any DRG reimbursement payor.
Any assistance or suggestions would be appreciated greatly.
Juanita B. Seel RN
Supervisor Documentation Management
Greenville Memorial Hospital
Greenville, SC
nurjbs@ghs.org
864-455-4981
We are now changing the process in Medical Information so that all discharged patient's medical records are scanned into the computer prior to coding. The coders will not see our doc-reminders to make notations on them. We will not get the hard copy of the doc-reminder back from the coder.
Can anyone tell me their process for the management of queries made concurrently but not answered until time of discharge? Do you keep hard copies of your doc-reminders or do they become part of the permanent record?
My department conducts 2500-2700 reviews a month and writes 500-900 queries each month. We query for every diagnosis that documentation is not clear and concise-- not just the ones that will increase re-imbursement. We want our medical record to stand against all outside auditors and we review all medical records for any DRG reimbursement payor.
Any assistance or suggestions would be appreciated greatly.
Juanita B. Seel RN
Supervisor Documentation Management
Greenville Memorial Hospital
Greenville, SC
nurjbs@ghs.org
864-455-4981
Comments
Your process sounds like mine. I communicate with the coder all of my queries in writing on a daily basis as well as any follow up. It's up to them to follow up after discharge, but I do get a report on the impact of my queries on the final coding of the chart which I report out monthly.
Copies of all of my queries are kept in a database that I built. There are no other reminders and queries, per policy, cannot be part of the medical record.
I hope this helps some.
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
"The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
If the query isn't answered before discharge or I miss the query through time issues then the scanning company removes the query before scanning the record and places it in a folder to be distributed to the coder which handles that alphabet section. She then assesses if the query has been answered and writes a note to that affect. Its placed in my box after that.
I attach it to the copy and place it in the answered queries. At the end of the month I divide them into "agree", "disagree", "unanswered", in terninal digit order. This goes into the file for the month.
Ay this time we are keeping the paper query although it has been entered in the software. However only the minimum has been entered. We keep the paper if there is a question as to how/why the query was written.
There have been some problems with getting the queries from prepping and scanning to the coders. We are relying on the copies of our queries a bit more lately. But that is a process improvement we are working on. Its a "follow through" issue.
We are still placing paper worksheets on the chart, even though more and more processes are in our EPIC system (for example, paper PN are virtually no longer in use, nor is H&P or DCS).
We do use the inbasket messages to present queries, but need responses in the PN, etc.
The CDI paper worksheets (that also contain a copy of the query) are scanned and placed into an administrative document type (if I have the wording correct), so are not considered a part of the legal medical record and would not be released with medical record ROI request. This is the same document type that the coder's attestations sheets are.
This makes the CDI record of work on the case available to the coding staff, as well as provides a direct way to access if needed (in the event that we change our CDI software, we will not have to maintain that CDI software as a repository.
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill
I have 5 full time and 2 part-time to cover outlying facilities. I will
review charts sometimes... so I have a total of 8 employees but only 7 FTE's