RE: New CDI program worksheets

Unknown
in CDI Talk Archive
Here is what I use, I print the lab flow sheet on the back.

It can be easily modified to meet your needs.



Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
5721 W. 119th Street | Overland Park, Kansas 66209
Charlene.Thiry@hcamidwest.com
Mobile: 913-498-6388
www.menorahmedicalcenter.com


Subject: [cdi_talk] New CDI program

Does anyone have any chart review forms you would be willing to share? I have only come across 1 in the CDI toolkit and was wondering if there were any more options available.
Thank you!
---
CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

---
Copyright 2010
HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945

Comments

  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    Charlene,
    Just a point I learned... anytime your going to transcribe lab results onto a query that will remain in the record, ie... a preprinted query, you must have normal lab values on it as well.
    We are using some preprinted query forms, they are very nice, the doc just checks the boxes and it says in the record, but we had to add all lab norms per JACHO standards.
    Amy

  • Unknown
    edited May 2016
    Hi Amy,
    The listed labs are on my worksheet, not a query.

    Charlene Thiry RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Quality Resources
    Menorah Medical Center
    5721 W. 119th Street | Overland Park, Kansas 66209
    Charlene.Thiry@hcamidwest.com
    Mobile: 913-498-6388
    www.menorahmedicalcenter.com

  • NormaBNormaB
    edited May 2016
    Amy,

    Was this on all your queries which offer LAB values? We have query templates where we offer LAB values but the CDS checks the boxes rather than the physician. It is in support of the diagnosis web are seeking.

    Are you saying normal (along with the abnormal we are checking) LAB values are being required in all queries?

    Trying to understand... :)

  • stacy.vaughnstacy.vaughn
    edited May 2016
    Amy, that was great information to share as a FYI to the group!! I like
    to give the physician supporting information on the queries which includes
    lab information.

    What section is that under in the JACHO book?

    Thanks!!!

    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052



  • robert.hodges2robert.hodges2
    edited May 2016
    Amy,



    I'd like that reference too please. And just to clarify, if I read
    this correctly, this would only be for queries that become a permanent
    part of the medical record. If a query does not become part of the
    medical record, then this requirement would not be present.



    Let me know if I have this right. I use standardized query forms but, by
    national policy, they are not to become part of the medical record.



    Thanks J



    Robert



    Robert S. Hodges, BSN, MSN, RN

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



  • robert.hodges2robert.hodges2
    edited May 2016
    It's policy for the Veteran's Health Administration only. It's usually
    up to the individual hospital in the rest of the world to decide If
    their queries become part of the medical record, and I'm told it can
    make a difference regarding the RAC.



    Sorry for the confusion.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



  • heidi.koenigheidi.koenig
    edited May 2016
    I work for a HCA facility and it is our policy to keep the queries as part of the medical record.

    Heidi Koenig, RN
    Clinical Document Specialist
    Ocala Regional Medical Center
    Heidi.koenig@hcahealthcare.com
    352-401-1686
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, November 04, 2010 3:54 PM
    To: Koenig Heidi
    Subject: RE: [cdi_talk] New CDI program worksheets

    It's policy for the Veteran's Health Administration only. It's usually up to the individual hospital in the rest of the world to decide If their queries become part of the medical record, and I'm told it can make a difference regarding the RAC.

    Sorry for the confusion.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602

    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov

  • stacy.vaughnstacy.vaughn
    edited May 2016
    Yes, it is our policy to keep as part of the record. Make sure you have
    "this is a permanent part of the record" on the form. Or something to
    that effect.

    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052



  • robert.hodges2robert.hodges2
    edited May 2016
    I'm probably not the best one to answer that question since my facility
    is RAC exempt. Exempt because VHA does not bill Medicare or Medicaid.



    There is some good information on the ACDIS Blog here:
    http://blogs.hcpro.com/acdis/category/racs/ that may help answer some of
    these questions.



    What I am sure of is that the smart folks on this listserve will be able
    to answer this question and will do so. I've learned a lot from asking
    questions here.



    Hope this helps some.



    Robert



    Robert S. Hodges, BSN, MSN, RN

    Clinical Documentation Improvement Specialist

    Aleda E. Lutz VAMC

    Mail Code 136

    1500 Weiss Street

    Saginaw MI 48602



    P: 989-497-2500 x13101

    F: 989-321-4912

    E: Robert.Hodges2@va.gov



  • stacy.vaughnstacy.vaughn
    edited May 2016
    It needs to say "this form is a permanent part of the Medical record".



    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052



  • heidi.koenigheidi.koenig
    edited May 2016
    You can look at this two ways. First, if RAC comes in and audits you, you may be able to use your queries as supporting evidence....On the other hand if you don't make them part of the permanent record you will have more leeway in wording. Queries are not supposed to be leading in any way. We have a REGS committee that approves our queries before putting into use. Hope this helps.

    Heidi Koenig, RN
    Clinical Document Specialist
    Ocala Regional Medical Center
    Heidi.koenig@hcahealthcare.com
    352-401-1686
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Thursday, November 04, 2010 4:11 PM
    To: Koenig Heidi
    Subject: RE: [cdi_talk] New CDI program worksheets


    It needs to say "this form is a permanent part of the Medical record".



    Stacy Vaughn, RHIT, CCS
    Data Support Specialist/DRG Assurance
    Aurora Baycare Medical Center
    2845 Greenbrier Rd
    Green Bay, WI 54311
    Phone: (920) 288-8655
    Fax: (920) 288-3052

  • acarducc@montefiore.orgacarducc@montefiore.org
    edited May 2016
    The RAC's are now requesting that queries be submitted w/a record. So it
    is important to have a query process policy that addresses if queries
    are a permaneny part of a record and that calls for revieew of queries
    to assure that they not leading as dxs could be disqualified by the RACm

  • fentona@bronsonhg.orgfentona@bronsonhg.org
    edited May 2016
    Hi all...
    I thought it would be easier to explain my prior statement w/ and example. I have attached an example of a query form (progress note) we use. We are supported by 3M and they provide us w/ query forms. The forms they provide us w/ are not readily accessible by outside agencies. They are scanned into the permanent record and can be accessed if requested by outside agencies.
    We have seven query forms we created that are part of the permanent record. They are actually titled "progress notes" at the bottom of them and placed in the progress note section of the chart. These forms have a section we fill out when we place them to support the query, some have lab values. On the ones w/ lab values we have to provide the "normal" reference range for that lab value. ( I just spoke w/ my boss again and she thinks it is either JACHO or CMS that dictates that under the "point of care" section. This was put in place around 5 or so years ago.) We have been very successful w/ the forms we created, they were approved by risk, compliance and many others before being put into use. The physicians seems to like them as well.
    I hope this clears up what I was trying to say initially.
    Thanks Everyone,
    Amy

    Amy Fenton, RN
    Clinical Documentation Specialist
    Clinical Operations Improvement
    Bronson Methodist Hospital
    601 John Street - Box 59
    Kalamazoo, MI 49007
    Office: (269) 341-8442
    Fax: (269) 341-8330
    Pager: (269) 513-3131
    E-Mail: fentona@bronsonhg.org

  • robert.hodges2robert.hodges2
    edited May 2016
    That is a very important point. I do make sure that all of my forms, even though they will never be part of the medical record, are approved by the compliance committee before use. I even type in the date they are approved by the committee on the bottom of the form. We also have our policy in place that states the verbal queries will follow the same format as written queries to ensure that queries are compliant to the best of our ability. As I recall that policy is on the ACDIS website if you want to see it or just email me and I'll send you a copy.

    Have a great Friday!

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
    1500 Weiss Street
    Saginaw MI 48602
Sign In or Register to comment.