response to query

ctrygarctrygar
edited May 2016 in CDI Talk Archive
I was wondering does anyone have issues with MD's answering a query in there progress note only once and not carrying it through the chart. Example query Acute Blood Loss Anemia the MD states it in his progress note the next day but then the remainder of stay and discharge summary doesnt mention it. How do you handle these cases and does your coders code it?


Thank you

cheri tyrgar Rn BSN


Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Yep, it happens all too often. I ask them if it is a continuing condition and if so it does need to be documented through the stay to include the discharge summary. Coders here also will tap the doc's on the shoulders to ask them if it was a continuing condition. It seems it's one of those things that requires frequent education and reminding.

    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
     
    "To climb a steep hill requires a slow pace at first."  -William Shakespeare
     

  • digardskdigardsk
    edited May 2016
    We try to get them to continue to document the condition, or note that it has resolved. Then, we keep our fingers crossed that they don't forget it in the d/c summary!

    Kim


  • nbrunson84nbrunson84
    edited May 2016
    Yes. The one I am currently working with is Acute Renal Failure documented in the H&P but Chronic Renal Failure documented throughout the chart. When I can catch it I query/verbal the Doc if it's "Acute on Chronic" (or what?) and to document within the Progress Notes or include it in his/her DC Summary.

    Currently, if it's documented, supported within the chart by clinical indicators and treated - we code it no matter how many times it is documented within the chart. It could be that it was a problem which cleared up w/in 24 hours w/fluids or blood. However - I would like to see it on that DC Summary and so would our coders.

    I do try to encourage as often as possible through education for them to carry out the diagnosis to the Discharge Summary.

    N. Brunson, RHIA
    Clinical Documentation Specialist
    Bay Medical Center


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016
    it happens to us too. They are getting better. Re: acute blood loss anemia - they will fill out our query form and may write in once on the progress note. However they will document anemia on an ongoing basis. The same goes for CHF and others.
    As long as they keep referencing the basic diagnosis we are not having any problems with auditors. We have not had any RAC requests yet though.
    We are audited by CGI for our Medicaid population and they haven't dinged us yet.



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