Non-agreement queries

donnaparton@cox.net

Is there a best practice for non-agreement queries? For example: the physician does not think the patient has sepsis but was queried for it. We see some of our physicians in a daily meeting and we could document a verbal response or get a response through our query process that is not part of the medical record (which would still need to be documented). Is documentation in the medical record, for example: no sepsis noted at this time, the best practice?

Thank you,

Donna Butler, RN, CDS

christina.borgony@ahn.org

If the criteria for sepsis is present thereby prompting you to write the clarification, the physician should be documenting "doubt sepsis, "  "no sepsis, " or some other phrase that negates that diagnosis. This will clarify the medical record, and will prevent coders on the back end review calling physicians to ask the same question again.

Thank you,
Christina Borgony RN, MSN, CDS

donnaparton@cox.net

Thank you, very good point!