Question about Photographs and Snipping Information to Queries

paul.taylor@sharp.compaul.taylor@sharp.com
in Clinical & Coding
We have electronic charts (EHR) and use email queries. Therefore it is easy for us to copy-and-paste wound photographs and laboratory tables using Windows Snipping Tool directly into queries as part of  "Documentation and/or Clinical Indicators."
The question is: are these photos and copy-paste additions good practice or do they make the query non-compliant and leading?

Comments

  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    Paul:  I am no lawyer nor Compliance Executive; but, will share my opinion.  Given that Best Practice Briefs state that a query must offer evidence of clinical support and context, I DO feel it is totally appropriate (and effective) to copy and paste relative lab values that are pertinent into a query.   Example:  If one issues a query re: renal function,  posting the pertinent lab results is certainly supported.  The results are a permanent part of the record, and the CDI is posing questions relevant by posting the proper results.  
    Paul Evans, RHIA, CCDS
  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu

    Should be no issue with providing pertinent data needed by the Provider to answer the query. It would be no different that actually typing out the lab values. For wound photographs I would just double check with compliance at your organization. If those photographs are already found in your organization's medical record then you aren't providing any new information.

    Jeff

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