Process for physician documentation of post discharge query responses

kelly.skorepa@uhhospitals.org

Our practice for completing queries that are not answered while the
patient is in-house is to request that the physician document their
response to the query via an addendum note/late entry written on a
progress note. I am seeking input as to where/how other facilities have
physicians document query responses regarding patients who have been
discharged. Any input re: process and/or forms would be much
appreciated!

Kelly



Kelly Skorepa RN BSN
Coordinator, Clinical Documentation Improvement
UH Case Medical Center Wearn 108
Tele: 216-983-5888 Fax: 216-844-8012
Pager: 38323
kelly.skorepa@uhhospitals.org

Unknown

The CDI writes a letter and or verbally visits with the physician
requesting an addendum be dictated or documented on progress note with
the current date and time. This letter is not part of the permanent
record, but the coders keep it in a file.



Patti Stewart RN, BSN, Clinical Documentation Specialist

kshumpert

My queries are not part of the permanent medical record. Post discharge, I either give a verbal query and have it written on a progress note. The other query I fax to their office with a blank progress note that is faxed back to me and added to the chart.


Kathy
Kathy Shumpert, RN, BSN, CCDS

Clinical Documentation Improvement Specialist
Howard Regional Health System
Office 765-864-8754
Pager 765-604-0424
Fax 765-453-8152

Writing comes more easily if you have something to say. ~Sholem Asch

dvitalone1

We are paperless, any suggestions on how to handle this
Dawn

robert.hodges2

I'm paperless too. Any query post discharge, including any follow ups
on mine, are done by the coders. I share my list of queries daily with
the inpatient coders via email so they know what I'm working on and the
status of the query.



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


"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens

sharon.cole

We are still using a paper record. If queries are not answered prior to discharge, the CDIS takes the record with query to the physician and verbally asks. They can respond by adding an addendum to the DC summary, a progress note, op note, etc. A few physicians will dictate an addendum.

Unknown

Could HIM add it as a deficiency for the physician to repond to in order to complete his record?

NBrunson, RHIA, CCDS

Unknown

Any queries issued after discharge are considered permanent parts of the record. We fax the query to the physicians office, he has room for a response, he faxes back and it is scanned into the record. This is all handled by the Coder/Lead Coder. The Lead Coder keeps up with a spreadsheet with all "after-discharge" queries.

NBrunson, RHIA, CCDS

ssalinas

Questions from another MT user:

Is this form a 'standard'? If so, where is it found?

A CDS?

Is it part of the EMR?

What is it attached to?


Thanks,

Sharon Salinas, CCS
Health Information Management Department
Barlow Respiratory Hospital
2000 Stadium Way
Los Angeles, CA 90026
ssalinas@barlow2000.org
Phone: 213-250-4200 ext. 3336
Fax: 213-202-6490

cstukenberg

Please tell us what version of Meditech you are using also.
Thanks.

ddraize

I would like to know also as we are upgrading to 6.0

Diane Draize RN, CPUR,CCDS
Clinical Documentation Specialist
Ministry Door County Medical Center
diane.draize@ministryhealth.org
920-743-5566 ex 3143

We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do