EPIC and Queries/Clarifications

cbelnap

Hello all,

I am looking for information about how other facilties with treatment teams (residents, attendings) are placing queries/clarifications concurrently? The limitation we find with using EPIC recommended practice of In-basket is that you can only assign to one provider, and follow-up or response to these are hindered by only being able to assign to one provider.

Sincerely,
Cara Belnap MS, RN, CCDS
Reg Ops Mgr CDI
Samaritan Health Services
cbelnap@samhealth.org

Linda_Rhodes

Hi Cara,
We have been placing queries in EPIC for over 2 years. We also have 4 residency programs and 2 large Hospitalists groups that rotate coverage. We built query templates in EPIC and the CDI staff create a note "type" Query and place in the progress note. It is a cosign note, although it does not require a cosign. The query is visible to all providers and staff who select that patient. We ask that the response be documented in a progress note and/or discharge summary. This has worked well for us. We occasionally send inbasket message reminders if a query is not answered within 48hrs.
Hope this helps!
Thanks,
Linda


Linda Rhodes RN, BSN, CCDS
Manager Clinical Documentation
Improvement
New Hanover Regional Medical Center
Wilmington, North Carolina 28402
Office # 910-815-5544
Cell " 910-777-8344
e-mail : linda.rhodes@nhrmc.org

evanspx@sutterhealth.org

We have residents, as well as mid-level clinicians, caring for our patients. The issue, is, as you stated, we can only address the query to one clinician. We typically address our query to the Attending of record, most often a Hospitalist. The Attending will often expect the Resident to answer the query on behalf of the Attending. The CDI query progress note is a legal part of the record, and any authorized clinician involved in the care of the patient can respond.

The Attending also countersigns the Resident's note. In the same fashion, a PA or NP may also answer a query as they are allowed to diagnosis (independently) per our By Laws...one issue might be if there is a discrepancy or inconsistency within the record; in this case, the query is sent to the Attending of record.



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

melanie.halpern

We use Outlook with subject line: Epic Documentation Question MRN and Room Number. We send "to" the provider who either wrote the note or ordered the tx plus the attending, and we "cc" the division director, the chief residents (for awareness and train-the-trainer opportunity), and our internal team: HIM director, impatient coding manager. We give screenshot(s) to show the relevant note that needs clarification, and we write our query narrative in the email body (these have been approved for use by HIM director/compliance). We give 48hr for response and send second notice, so they get a total of 72 hrs to respond. We target inpatients w 48 hr admission, and will do "re-review" as necessary up to three days post discharge.
We keep a scorecard by service line for the areas we cover, and report results to revenue cycle and service chiefs as necessary.

Melanie Halpern
Supervisor, CDCI
Newark, NJ

david.reecern

I wish we had gone with the progress note option like Linda stated but if you opted for the inbasket way then you are stuck being able to send it to one provider unless you duplicate the query and send it out. I've heard there is a change in that feature with the next EPIC upgrade which we are supposed to get in August. Not sure if anyone else on here has already received the 2014 upgrade and can comment??
David Reece, BSN, RN
Manager, Clinical Documentation Improvement
Clinical Improvement
Novant Health
cell: 336-480-7541
office: 336-277-1935
fax: 336-277-8045
dreece@novanthealth.org

clemed12

We follow Owensboro's practice. We use a shared note format in Epic which is typically responded to within 24-48 hrs. If not it is assigned as a deficiency for the attending and is placed in his in basket in his deficiency folder where he is accountable for responding. Our query is cut and pasted from Clintegrity as a compliant query and becomes part of the permanent medical record.
Hope this helps
Diane Clement

m.leblanc

I did not see that in the 2014 upgrade but maybe the facility chose not to turn it on.

Thanks,

Mark

MARK LEBLANC, RN, MBA, CCDS

DIRECTOR CDI SERVICES



952-353-3505

m.leblanc@thewilshiregroup.net

deanne_wilk

We just started putting our queries on the chart as a progress note and permanent part of the chart. We also then send out a copy of the query via email from 3m 360.
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

evanspx@sutterhealth.org

With our version of EPIC, we compose the progress note, and a notification of the CDI query is automatically sent to the Clinician’s E-mail account within EPIC. A deficiency is generated within EPIC, asking for a response to the CDI Query.

Paul

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