Re: Concurrent Query a permanent part of the medical record.

paxnerospaxneros
in CDI Talk Archive
We do. The directive is for them to answer in Progress notes..
With auditors being so picky regarding documentation its good to have proof the questions were asked while the documentation was being generated.

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Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    We use EPIC and the response is a progress note that is a permanent part of the record..IMO, this is Best Practice.

    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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