HELP~

Good morning! Can someone help me with a question? While I know we cannot introduce NEW information for queries etc. If a provider says "please see detailed information from DRs initial report dated yesterday" can we use info from that relative to a query? This pt was a tx patient from another hospital so can we glean info from it since the provider here tells us to "see the detailed info" from that report. Thanks!

I think we can, but wanted to see what the general consensus was. TIA@

Juli

Juli Bovard RN CCDS
Certified Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
755-8426 (work)
786-2677 (cell)
"No Limit to Better......"
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Comments

  • I SHOULD have clarified "new info" meaning from prev admits...

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, December 04, 2014 10:10 AM
    To: Bovard, Juli
    Subject: [cdi_talk] HELP~

    Good morning! Can someone help me with a question? While I know we cannot introduce NEW information for queries etc. If a provider says "please see detailed information from DRs initial report dated yesterday" can we use info from that relative to a query? This pt was a tx patient from another hospital so can we glean info from it since the provider here tells us to "see the detailed info" from that report. Thanks!

    I think we can, but wanted to see what the general consensus was. TIA@

    Juli


  • edited April 2016
    This discussion has been held with our hospitalists. They are big on readmits saying 'see previous H&P or DC summary'. My response to them is if that is what they want to use they must date and sign it for the current admission. If not queries may be forthcoming to clarify (i.e what are all those medications for etc. . . .)

    Charlene

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