Electronic Record Query Process

fosterma

We have a total electronic record [EPIC] and do our queries/clarifications electronically. We are interested in knowing from those of you the following:
1. How you query/send clarifications in your electronic record?
2. How do you get your responses?
3. If you have EPIC, do you use a. In-basket system
b. Sticky Notes to providers c. other [please describe] d. combination of a & b.

4. Do you have a written policy & procedure for Concurrent Query/Clarifcations, either EHR or paper chart reviews.

Thanks for your help.
Roberta Fosterman RN
Clinical Documentation Specialist
Oregon Health & Science University
Portland Oregon 97239
fosterma@ohsu.edu
503-418-4024
fax 503-494-8439

robert.hodges2

I also have a 100% EHR (VistA). I am not allowed, by VA Directive, to do electronic queries because the query cannot become part of the medical record. I primarily either do a paper request or a verbal request with the provider. The only accepted responses are those documented in the medical record. Of course if the discussion results in no change I still document that in my tracking database and close the query.

Now one place in the VA is doing electronic query requests via a provider alert message. The problem is they have to go in every 3 days and remove the alerts so they don't stay in the medical record.

I do have a written SOP to cover the clarification requests. A copy is attached. It does work well. Feel free to let me know if you have any questions.

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
 

laura.jansen

We are also moving to a total electronic record in October. We are using meditech. I am also interested in how everything will work out.

nbrunson84

We are going "live" on Horizon Patient Folder next month. Currently we are talking of "batch scanning" our CDI Queries each day - or several scheduled times a day. We have templates and "tweak" each query according to the documentation needed. We usually formulate them in Microsoft Word, print them out and place them on top of the progress note section in the chart.

In "theory" they will now be formulated, printed,scanned and entered into the chart as a "Query" which the Dr. must review and process. (I will probably also leave the paper copy on the paper chart on the floor until we completely evaluate this process thoroughly)

Discharge Queries will be processed much the same accept they will be scanned and added as a "deficiency" for the Dr. His answer will be "typed" into the edit box provided. Our discharged queries - or queries issued by the final coders are retained permanently within the chart.

Unknown

We have moved to an electronic record using Meditech. Unfortunately, the physician note system is still having problems and isn't out of test mode, so I have not been able to send electronic queries to the physicians. It has become very difficult with the physicians looking at the electronic record and not always the chart. I have to do a lot of verbal queries and tracking the physicians down or getting them to remember the request is a challenge.
If anyone has any pointers on Meditech please let me know.

Lisa Taylor, RN
Documentation Improvement Specialist
Wooster Community Hospital

ddraize

Hi Lisa I don't have any pointers on Meditech because we are looking at moving to complete electronic next year. So could I get your email, so I can pick your brain than. Thanks
diane.draize@ministryhealth.org