Quick survey: permanent queries

careedcareed
in CDI Talk Archive
I am gathering info regarding Queries as part of the permanent record and wanted a few opinions. Can you please spare a minutes and reply? Thanks for your time!


1. Are your queries Paper or Electronic?

2. Are you queries permanent records?

3. Pros or cons of having permanent records, or other comments.



Christine Reed, RN, BSN
Clinical Documentation Specialist
CDIP Team Leader
Elkhart General Hospital
Phone: (574) 389-5665
Pager: (888) 301-9402
Please note my new e-mail address:
Email: careed@beaconhealthsystem.org

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Comments

  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited April 2016
    Responses below.
    Thanks,

    Donna Fisher, CCS, CCDS
    Clinical Documentation Improvement Supervisor
    UFHealth - Shands Hospital
    352.265.0680 X 48769
    fishdl@shands.ufl.edu
  • annnd2009@gmail.comannnd2009@gmail.com
    edited April 2016
    1. Electronic
    2. Permanent
    3. My opinion it should be required with increased focus on transparency.
    Non-permanent would make scrutinize harder if I were an auditor. Don't you
    have to retain then if requested when not part?

    Sent from my iPhone

  • careedcareed
    edited April 2016
    Yes, our queries are discoverable, although they sometimes get removed from the chart, as they are still paper. We are going electronic in a month. It seems logical to make them permanent, I just need to get everyone to agree.

    Thanks for the responses so far!

    Christine Reed, RN, BSN
    Clinical Documentation Specialist
    CDIP Team Leader
    Elkhart General Hospital
  • ggoodman@virginiahospitalcenter.comggoodman@virginiahospitalcenter.com
    edited April 2016
    Or queries are paper and are not part of the permanent record.
    That will likely change once we go all electronic….
  • dallend@einstein.edudallend@einstein.edu
    edited April 2016
    HI- see my comments below



    Deborah A Dallen,RN, CCDS
    Albert Einstein Medical Center
    Phila PA 19141
    Clinical Documentation Coordinator
    Health Information Management
    215-456-8902
    >>> CDI Talk 6/20/2014 8:04 AM >>>

    I am gathering info regarding Queries as part of the permanent record and wanted a few opinions. Can you please spare a minutes and reply? Thanks for your time!

    1. Are your queries Paper or Electronic? Both, concurrent are paper, post discharge are electronic. We have a hybrid record - progress notes are still on paper.
    2. Are you queries permanent records? We have some queries that are permanent and others that are not permanent. Queries to clarify diagnoses such as documented CHF, Anemia, CKD are permanent. When we are trying to clarify issues s/s or abnormal labs - we use forms that are not permanent. The physician replies in the progress notes. The forms that are not permanent are removed from the chart and maintained in our department.
    3. Pros or cons of having permanent records, or other comments. Pros - the form is in the chart and we don't have to worry about storing it. Auditors can clearly see that we queried - we only use permanent forms when the diagnosis is documented and we are clarifying the etiology. Cons - MDs do not always continue to document the diagnosis in its' entirety and they may forget to include the clarification in their discharge summary (no matter how many times you remind them). You need to train your staff well regarding when to use the form - to ensure that it is not placed on the chart inappropriately such as when only s/s are documented but the reviewer really thinks the patient has CHF, etc.



    Christine Reed, RN, BSN
    Clinical Documentation Specialist
    CDIP Team Leader
    Elkhart General Hospital
    Phone: (574) 389-5665
    Pager: (888) 301-9402
    Please note my new e-mail address:
    Email: careed@beaconhealthsystem.org


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    1. Electronic since may 2012

    2. Permanent

    3. In my opinion it is simpler and more transparent. The MD can respond right in the query when they see it as opposed to having to remember later.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    1. Electronic (EPIC)

    2. Permanent

    3. Advantage of Permanent: Transparency. Conditions should be researched before a query is issued - when clinical factors support the query and the query has an MD response, the query has 'integrity'.

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.412.9421

    evanspx@sutterhealth.org

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  • Unknown
    edited April 2016
    1- Fully Electronic - since 2013
    2- Permanent
    3- Easier to get replies for the most part, learning curve when first initiating- after that just catch new MD's and teach how to answer.

    Jamie Dugan RN, CCDS
    Clinical Documentation Improvement Specialist
    Baptist Health System
    Jacksonville, Florida

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