Verbal queries

Mabraham

Good afternoon,

We are currently implementing a CDI program at the hospital where I am employed. With that being said, we are having discussions in regards to whether verbal queries need to have physician signature. Does anyone have any feedback as to what their current best practices are? Our Director of Revenue Cycle feels that these should be signed, but he's also sensitive to the fact that this might be unreasonable. Does anyone have any feedback in regards to this topic?

Thank you,

Matt Abraham

Director, Case Management & Clinical Documentation

mabraham@ohiovalleyhospital.org

412-777-6506

cindys@hollandhospital.org

Hello

Our verbal queries are documented by the Clinical Doc Coordinator and are not signed by Provider

Cindy

Jane.Brown@ensemblehp.com

Matt,

Our verbal queries are documented by the CDI RN and they are not signed by the MD.  However, verbal queries are held to the same standard that written queries are when it comes to compliance.  It is important to show that you are not leading the physician when documenting a verbal query.

Hope this helps.

Janie

pjdave1985

Hello Matt,

   We do ask verbal queries when we are on floors for multidisciplinary rounds. We request physicians to document in their progress note f they agree to it. That way it is part of record. Hope this helps.

jackietouch@aol.com

Our verbal queries are maintained in our CDI software (not part of the medical record) and adhere to AHIMA standards for compliance. The CDS makes sure the diagnosis is documented in the medical record by the MD if agreed, then indicates in the software the appropriate disposition. No MD signature is required for queries because agreed to queries are already documented in the medical record.