Post Discharge Query Follow-up

Unknown

We are interested in learning about the CDI/HIM post discharge query process in other facilities. Responses to the following questions would be most appreciated.

1. Are the Clinical Documentation Specialists responsible for unanswered queries post discharge? If so, how much time does the specialist have to get responses to these queries?

2. What is the mechanism in place to get the physician response into the medical record?

Thank you.
Stephanie Samuels, MS, RN, CCS
Clinical Documentation Improvement Manager

dbutler

For us, there is an understanding that the CDS will attempt to get a response immediately post discharge (not more than 48 hours, typically more like 24). After that point, success is much more difficult & we start to get into the time frame where coding is starting.

The Coding staff are expected to review any queries posed by the CDS and if a response wasn't received (about 10% no-response rate), or if the response was not strongly documented, then a follow up query will be presented by the coder if the information is still needed and will either make a financial or a significant severity/coding quality difference.

For the CDS follow up, the response is still needed in the medical record -- either incorporate into the DCS if not completed, a DCS addendum or a late PN.

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com


Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill

dallend@einstein.edu

We are responsible for ALL queries. Our coders do not query physicians.
We f/u on our unanswered queries and also do coder requested queries post discharge.
We give the physicians 2 weeks to answer the query - after that they get fined a nominal amount every day the query goes unanswered. After the first week we will forward the unanswered queries to the chief residents for medicine and the chair of medicine or the administrator for the dept of surgery and the chair of surgery. Most of the time the threat of forwarding the query usually causes the resident to answer the query.
Our charts are scanned post discharge. We enter the query electronically and the MD places an addendum in the appropriate section of the chart - usually progress notes, consult, OP report or discharge summary. We text page the physicians every day until the query is answered.
We only have 1 or 2 unanswered queries (concurrent and post discharge) per month.

Deborah Dallen

Unknown

Here it is the Clinical Documentation Specialist's obligation to get their own queries answered. We have 48 hours post discharge to accomplish this. If for some reason this is not done, the coder takes over which leads to a deficiency on the physician's part.

I fax the outstanding query, hunt the physician down during the day, call the office etc. If I place a query on an inpatient record which has discharge orders I immediately fax it.

All in all we have 98-99% response rate. Most response occur while the patient is still in house. There still are a few reluctant physicians - these I really look for when they round.


Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
5721 W. 119th Street | Overland Park, Kansas 66209
Charlene.Thiry@hcahealthcare.com