RE: [MARKETING] [EXTERNAL] Templates

wendy.clesiwendy.clesi
edited May 2016 in CDI Talk Archive
Templates can be a great tool to improve CDS efficiency/productivity and to serve as a teaching tool for new CDS. It has been my experience that templates are often misused and do not comply with the recommendations outlined in the 2013 AHIMA Query Practice Brief: Guidelines For Achieving a Compliant Query Practice. The two most common issues that I have seen are 1) use of a titled query form when the diagnosis is not already present in the medical record and 2) menu options are not modified to include "clinically viable" options specific to the individual patient. If you opt to use query templates, I would recommend doing extensive education regarding appropriate use of the forms and institute a query compliance QA process if you don't already have one in place.

Wendy

Wendy Clesi, RN, CCDS
Director CDI Services
Huff DRG Review
985-778-8489
Wendy.clesi@drgreview.com



Sign In or Register to comment.