Query Format
Recently physicians have been saying that they want the questions first in the query so that they know what we are asking when they look at the clinical indicators and treatment.
Our team has been discussing if there is any written rule that states that the question part of the query cannot be presented before the clinical indicators and treatment in a written query. If the question is not leading, and if the suggested diagnoses are appropriate and the question includes clinically unable to determine/unknown is offering the question first a compliance problem?
I was unable to find written direction, but that doesn't mean it's not out there. Any information would be helpful.
Thanks,
Lori Harbison LPN, CCDS, CDIP, CCS
Comments
Hi Lori,
No, posing a non-leading questioning is not against the AHIMA/ACDIS Practice Brief standards. In fact, an "opening statement" is recommended in the CDI community. I implemented this practice when I took over at a new facility. We have seen our response rate and agreement rate increase tremendously, from all physician specialties. That was a frequent complaint prior to my arrival - that the provider did not understand the question, what was being questioned, and why.
If we put ourselves in physician's shoes, it makes sense. They are very busy with managing and treating the patient that they do not always get caught up in documentation, especially ensuring that every note and word is "accurate" documentation. (That's why we're here!) I have found that including a non-leading opening statement has been very helpful and successful in improving our physician engagement and increased respect for CDI from the physicians.
Non-leading opening statement examples:
1. "Please clarify the condition treated with IV Lasix." (For a scenario which shows acute CHF but they are not documenting such.)
2. "Documentation within the medical record is considered conflicting. Please clarify the diagnosis." (When the provider conflicts his/her own documentation or a consult.)
3. "Based upon further study, please clarify the underlying cause of GI Bleed." (When a patient is admitted for unspecified GIB and EGD shows specified cause or source.)
4. "Based upon further study, please clarify the condition chiefly responsible for occasioning the Inpatient Admission from Observation." (When a patient was admitted as OBS but then changed to IP later or based upon further workup.)
5. "There is a one-time mention of "Sepsis" documented within the medical record. Please clarify the status of the condition." (When Sepsis is documented once, usually by the ED Note, and is needs to be ruled. Or, when Sepsis is valid but is not continued as a dx in documentation beyond the ED note or H&P.)
6. "Documentation specifies "Pneumonia". Please clarify the type." (When pneumonia is diagnosed in the record without specification but treated as a complex pneumonia with specific antibiotics.)
7. "Documentation in the medical record shows "diastolic heart failure". Please clarify the acuity." (When the provider does not document the acuity of HF. You can also use this one and ask to clarify the "type and acuity" when neither are documented and HF is documented and valid.)
These are just a few. I hope this helps!
Remember, it can be tricky and it takes a special thought process when determining how to build an opening statement to convey "what" and "why" you're asking the question. Some CDSs struggle with this very part, which I would advise them to reach out to others and print their own examples for future use. Practice makes perfect! But you will see a better relationship and response rate from your providers.
One more point: Clarifications are also to "educate the provider" on documentation. This is done with an opening statement because it identifies what is wrong with the documentation. And of course, follow your opening with your multiple-choice options and 3-part query format (clinical indicators, risk factors, and treatment). Your options should always be reasonable diagnosis options for the question and clinical indicators listed.
Thank you, and good luck implementing this small change (but well worth it) to your query practice!
- Angelica Naylor