Concurrent Query a permanent part of the medical record

lindenbmlindenbm
in CDI Talk Archive
I was wondering how many of your institutions have the answered concurrent query kept as a permanent part of the medical record. Our concurrent queries have been a permanent part of the medical record since going to an electronic health record. Some of our doctors don't like it as they feel it is a red flag.

Thoughts?

Mary Lindenboom, BSN, CCDS
Clinical Documentation Improvement Manager
Flagler Hospital
Saint Augustine, FL
904-819-4254
mary.lindenboom@flaglerhospital.org

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited April 2016
    Ours are a permanent part of the medical record. I personally feel that this preferable. However, my understanding is that regardless of them being a permanent part of the medical record, they still should be held to the same standard, are discoverable, should be stored, etc...
    To me, a query is only a 'red flag' if it is unsupported. If there is sufficient clinical indicators to support a query and the query is compliant, there should not be an issue.

    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


  • m.leblancm.leblanc
    edited April 2016
    Katy, I totally agree with your comments.

    Thanks,
    Mark

    MARK LEBLANC, RN, MBA, CCDS
    DIRECTOR CDI SERVICES

    952-353-3505
    m.leblanc@thewilshiregroup.net



  • rmhosler1rmhosler1
    edited April 2016
    Permanent at our hospital in michigan.MARY


  • deanne_wilkdeanne_wilk
    edited April 2016
    We just made ours permanent. Does anyone have 3m that switched from not permanent to permanent? Do you know how they handled the templates in 360 to accommodate this. I am being told I have to go through each query and change them one by one and make all new queries just to take the word “NOT” out of them.


    Deanne Wilk, BSN, RN, CCDS, CCS
    AHIMA approved ICD-10-CM/PCS Trainer

    Clinical Documentation Improvement and Inpatient Coding Manager
    HIMS Department
    Good Samaritan Health System
    4th & Walnut Sts
    Lebanon, PA 17042
    dwilk@gshleb.org

    Phone: 717-270-7582
    Cell: 717-580-1436



  • amkelly3@partners.orgamkelly3@partners.org
    edited April 2016
    Hi there
    We just made ours permanent too. The providers like the check and sign feature but I'm seeing that they are not carrying the compliant documentation forward...
    Brigham and women's Faulkner Hospital CDI program is presenting a poster at the conference next week on our medical record query .... Stop by!
    Andrea Kelly
    BWFH CDI Program Director

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    Agree w/ Katy's input...as long as we issue queries compliant with the AHIMA/ACDIS Best Practice, we should not have any issue.

    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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