removing queries

Nancy.Franciotti@renown.orgNancy.Franciotti@renown.org
in Clinical & Coding
Coding is requesting that CDI "un-chart queries" when a patient is discharged in order to prevent conflicting documentation once a chart has been coded. We have Cerner and the queries go to physician message center. It will mark our query "in error" so physician won't answer. Is anyone familiar with this process?

Comments

  • ssavinsk@valleyhealthlink.comssavinsk@valleyhealthlink.com
    Are your CDI queries part of permanent medical record? if so, can coder capture dx. from the response or does it have to be re-documented in the progress or dc/ summary?
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    The queries are either a part of the ‘administrative’ record or are recognized as a permanent part of the medical record, as determined by your site.  I suggest a conversation with Compliance.  The record should not be altered in my opinion and the query should remain.  There are JCAHO and State Regulations pertaining to correction of the record and there should also be formal regulations addressing precisely how a record may be ‘corrected’ per your local by laws.  All of these address the ‘correction’ of a record, to include how to delete entries ‘made in error”, such as an entry into an incorrect account. However,  I am not familiar with any regulation that would support removal of a query for the purpose stated.

    P. Evans, RHIA, CCDS
  • Nancy.Franciotti@renown.orgNancy.Franciotti@renown.org

    Thanks so much for responding Paul. In Cerner there may be a way to un-assign the query to the physician in cases in which the coder feels the query is no longer needed. What are your thoughts on that practice?


  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    It is difficult to respond as I don’t have knowledge of Cerner. In essence, you are saying you may have a pending query for ATN charted in Cerner, but subsequently, the ATN is stated and you feel the query is no longer needed?  In such cases, you un-assign the query?  Something like that?

    I can tell you in ‘our’ workflow, our query is in the form of a progress note that is filed in the MD Progress Note Section.  We have a very active Residency Program, and often a Resident or Hospitalist will answer a query, even if not assigned to them directly.

    SO...key point...our thoughts are IF a CDI issued a query for ATN, and the language is later charted, even if there is not a direct answer to the CDI query,  we leave the query charted so that anyone auditing the case can see the question was posed by the CDI team.  
    Hope this makes sense..it is a bit complicated.

  • Z620jb@gmail.comZ620jb@gmail.com
    We use Cerner, and have our queries as a permanent part of the record. As the human factor intervenes sometimes, we do in error a query (like when it was put in the wrong chart) and remove the deficiency from the queried provider if no one has signed or modified the query. But it stays in the chart with the reason the query was in errored (such as wrong pt.) If the provider responds to the query  on a progress note or discharge summary, we addendum the query only stating the location of the response ( writing what the answer is, in my view, is noncompliant) and close it out. If the provider signed only or answered on the wrong patient/ query/ etc., we have to leave the query as is; and as the Manager, I look case by case as to how to handle it, usually writing a note on the query to state what happened and what we did. Luckily those are very rare..  As far as removing queries per Coding request, we don't do that, the Queries are permanent. I agree with Paul, check with Compliance if you are having that gut feeling....  
  • Nancy.Franciotti@renown.orgNancy.Franciotti@renown.org

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