Poorly written Query ?

littlebit_62703@yahoo.com

Hello,

when constructing a query, in the risk factors and the treatment options section, if you forget to add the source document and date, does that make the query a poorly written query according to industry standards?

Thanks

annnd2009@gmail.com

I'm so mouthy today!! poorly written maybe, invalid or leading, I would say no.

I would say yes, poorly written, because if the provider wanted to validate it, it could cause more of a challenge. Ideally you want to make that easy for them.

That being said, some would argue, that without everythign being pefect in a query, it's leading, but that is not what the practice brief said in 2016 "

A leading query is one that is not supported by the clinical elements in the health record and/or directs a provider to a specific diagnosis or procedure." I can't find the same terminology in teh 2019 practice brief but I also do not feel it says a non-dated reference is leading.
I think we scrutinize so much we can be fixated on rules and lose site of the big picture. If the diagnosis is truly supported the medical record should provide the supoort to be compliant. But BEST PRACTICE,  ( or not poorly written), would ideally cite the reference so that anyone can validate, quickly where in the chart the evidence resides.

evanspx@sutterhealth.org

I believe it is ‘best’ to include the date/time of the source documents as this should make it much easier for a busy clinician to consider the query and respond.  I have witnessed some queries that say..’the record documents xx” with no further details.  Sometimes these are RN notes that are being mentioned, sometimes RD, sometimes MD...etc.

Always much better to state the date and author in such citations IMO.

littlebit_62703@yahoo.com

Thank you. so the wording is really best practices to ensure this information is there not poorly written thank you both I appreciate it 

drew.siegel205

We need to document in our queries as well as we expect the clinicians to.  ;-)

hooter1964

The goal: Make sure it is written so that your provider does not need to go back in the record at all to answer your Query. Whatever it takes. So yes, source everything.