Query a part of the medical record?

hillsandovals@email.chop.eduhillsandovals@email.chop.edu
in Pediatrics
Hello fellow CDI. I was wondering if your CDI dept, have made your query a part of the medical record? Also if so, do your coders send out queries as well?

Thanks in advance for your feedback.
Stephanie
CDI Team lead
Children's of Phila

Comments

  • kathryn.goodkathryn.good
    Yes, ours have always been a part of the permanent record. Both coding and CDI used to send queries but as of a couple years ago CDI now handles all queries, concurrent and retrospective....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


    -----Original Message-----
    From: Pediatric CDI Talk [mailto:pediatric_cdi_talk@hcprotalk.com]
    Sent: Friday, April 15, 2016 1:51 PM
    To: Kathryn Good
    Subject: [pediatric_cdi_talk] Query a part of the medical record?

    Hello fellow CDI. I was wondering if your CDI dept, have made your query a part of the medical record? Also if so, do your coders send out queries as well?

    Thanks in advance for your feedback.
    Stephanie
    CDI Team lead
    Children's of Phila
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  • jackietouch@aol.comjackietouch@aol.com
    Hi, Stephanie ~

    Yes, our electronic clarifications are saved in the medical record under a "Documentation Review" folder. For clarifications that are obtained verbally during rounds or conversations by phone, the provider updates the diagnosis list and/or progress note in real time. The CDS may also mark the verbal response on the CDI worksheet (which is not a part of the medical record).

    Coders also send post-discharge queries (we differentiate clarifications as being concurrent, queries as being retrospective) using their template/forms. They are always sent electronically and are part of the medical record.

    Hope this helps,
    Jackie Touch, MSN, RN, CCM
    CHOC Children's
    jtouch@choc.org
  • jackietouch@aol.comjackietouch@aol.com
    Great discussion that has brought to mind another question:

    If you don't mind me asking: For programs in which CDI does all the queries (concurrent and retro) what ratio of discharges per CDS is used to determine staffing? We have 3 CDSs in our program and I can't imagine doing both concurrent clarifications and retro queries!

    Thanks in advance,
    Jackie Touch, MSN, RN, CCM
    CHOC Children's
    jtouch@choc.org
  • kathryn.goodkathryn.good
    We have some restructuring happening right now so I don’t have the exact FTE/discharge data but we are 'well-staffed' I believe. That being said, retro queries are only about 5% of our total queries so while it does increase workload, it's fairly slight. The benefit of CDI performing this task I believe is significant as we are able to learn what we are missing. Also it keeps queries consistent and allows for quicker response as CDI tends to have better access to the physicians.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


    -----Original Message-----
    From: Pediatric CDI Talk [mailto:pediatric_cdi_talk@hcprotalk.com]
    Sent: Sunday, April 17, 2016 11:06 AM
    To: Kathryn Good
    Subject: RE:[pediatric_cdi_talk] Query a part of the medical record?

    Great discussion that has brought to mind another question:

    If you don't mind me asking: For programs in which CDI does all the queries (concurrent and retro) what ratio of discharges per CDS is used to determine staffing? We have 3 CDSs in our program and I can't imagine doing both concurrent clarifications and retro queries!

    Thanks in advance,
    Jackie Touch, MSN, RN, CCM
    CHOC Children's
    jtouch@choc.org
    ---
    CDI Talk is offered for networking purposes. For official rules and regulations related to documentation and coding, please refer to your regulatory source.

    You are receiving this message as a member of Pediatric CDI Talk as: kathryn.good@nahealth.com If you would like to be removed from Pediatric CDI Talk, please send a blank email to leave-pediatric_cdi_talk-20296405.a2514b61f11907a0877151f9c3576acd@hcprotalk.com
    ---
    Copyright 2013
    HCPro, Inc., 75 Sylvan Street, Danvers MA 01923 This message has been scanned and no issues were detected.
    Do not trust links or attachments and do not divulge sensitive information upon email request.

    To report this email as SPAM, please forward it to spam@websense.com
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