Progress Notes Now Electronic - No Way to Query - Help!

ggoodman@virginiahospitalcenter.com

Our hospital went live with electronic progress notes this past Tuesday.
Unfortunately, an electronic query process for the CDI specialists will not be able to be built and implemented for another month or more.
So we are in a bit of a pickle right now.
Has anyone else ever been in this situation and if so how did you complete your Queries?
We have tried reviewing our records on the floor with the hope we might be able to catch the physician we need if we find a query opportunity, but thus far have had no luck with this method. The doctors that we do see are trying to learn the new electronic system, so I'm not sure if they would take kindly to us interrupting them anyway.

We are trying to brainstorm alternative methods for Querying until our electronic part is built.
Any thoughts/suggestions?
Has anyone had success with:
Paging physician
Calling physician
Faxing query to physician office
e-mailing query to physician
Trying to find the doctor on the floor
Attending daily huddles and going over queries with docs at that time
Other _______

Thanks so much!
Greta



Greta Goodman, CCDS
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com


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cprice

We went live with electronic progress notes over a year ago. They are still
trying to implement an electronic CDI query process. Our current process
includes placing a written query in the chart hard cover (the ED is still on
paper). The physician's don't usually see the queries there so I page them
and advise that there is a query for a particular patient for them to address.
I find that most of the time I end up reading them the query. They will
usually go in and update the record from wherever they are when they answer
the page. If they do not respond to the page attempts we send an email
notifying them of the attempt to contact. We sometimes have to escalate for
no response but our response rate is well over 90%.


Cheryl Price, MSN, RN
Clinical Documentation Improvement
Riverside Co. Regional Med. Center
26520 Cactus Avenue
Moreno Valley, CA 92555
951-486-5036

vsmith123

We have 2 small hospitals that we manage remotely. We are currently using secure e-mail to send our queries directly to the physicians. Our response is pretty good. They do not document on the queries, we ask that they use their progress notes or d/c summary.
Vickie Smith RN, BSN, CCM, CCDS | Clinical Documentation Specialist-Manager | 740-779-7548 | vsmith@adena.org
Adena Health System | Clinical Documentation Integrity Program
272 Hospital Rd. | Chillicothe, OH 45601
Phone: 740-779-7548

rmhosler1

Greta:We have had good success w faxing to the office. However, we only do it when a query has not been answered post DC and then only if the chart is held up for a month or so. 
We are also in your situation but the electronic progress notes are not mandatory for all physicians. We are still catching them on the floor etc. We would like to do email but there is hesitancy about HIPPA. Even with secure me. They also want a way to ensure the email is from the person intended and we need to figure that out. 
We are changing to a new EMR so it is going to be longer for us.

lindenbm

We went from a hydrid record to totally electronic record in July 2013. For over one year we were not able to do concurrent records and did only retrospective queries. We reviewed charts of patients discharged the day before and did queries. We also did retro queries requested by the coders. Last September we finally went live with concurrent queries in our EMR. The answered query would then populate into the physicians progress note. As you can imagine the physicians hated it as did we. So we again had a list of docs that we couldn't concurrently query. We work diligently with our IT department and just last week started concurrently querying all physicians. The query pops up when the physician saves his progress note or consultation. It is a hard stop and he must answer the query. The answer then populates back into the CDI query document. We love it. But it was a lot of hard work to get it the way we wanted it to be and be compliant with the AHIMA guidelines. If you have any questions please feel free to give me a call.
Mary Lindenboom BSN, CCDS
CDI Manager
Flagler Hospital
St. Augustine, FL
904-818-4254
Mary.lindenboom@flaglerhospital.org