Queries as part of the medical record

stoddardrvstoddardrv
in CDI Management

I can't believe I am revisiting a topic last discussed here in 2016, but one of our doctors is wildly uncomfortable with the idea of queries being a permanent part of the medical record, (i.e., being discoverable). I've pulled up the ACDIS/AHIMA Consensus paper, the Final Ruling, and now am looking for other hospitals that also keep their queries in either the medical record or the legal record. We know it's best practice. But I'm looking for more ammunition. Help!

Comments

  • ldaniels1ldaniels1

    We send all CDI queries through our EHR via InBasket and they are part of the legal medical record. This is the same process that is used for coding queries. Before we began sending queries this way, we also had some concerns raised with having CDI queries part of the permanent medical record. We addressed specific concerns by involving legal, risk and compliance departments. Do you know what is making your provider uncomfortable with it?

  • mancika1mancika1

    We started using electronic queries almost 2 years ago. Since last year (I think October), we left is as part of the permanent medical records. 2 months later we changed our retrospective query process to use the same electronic format and it is also part of the medical record. It is discoverable anyway and if it is part of the medical record, the coders can code from it, while if it is not, they could not code from it. The doctors love it as it is right in the system that they use on a daily basis.

  • m1ghtymurs3m1ghtymurs3

    Couple of things.

    I would really try to find out what the source of the discomfort is. If you have a physician advisor maybe ask if they can have a conversation with the provider. If you don't have a PA, maybe have your Director or somebody higher up in the chain try to find the exact reason.

    Another option, if it just one Provider, you can always give them the option of adding an addendum instead of answering the query. But this can also open a can of worms, however, better than not being able to get query answers.

    Hope that helps!

  • Robin.Matthews@mainehealth.orgRobin.Matthews@mainehealth.org

    Our EMR is Epic and CDI software is CDE ONE. Our queries are sent electronically and are discoverable within the medical record.

  • rmcintosh2469@gmail.comrmcintosh2469@gmail.com

    We are in the early process of sending queries via Meditech. We have a few questions.


    1. Can the queries in meditech be answered with an X on the query and then be coded by the coder, as it would then be part of the permanent record? 
    2. If we make the concurrent query part of the permanent record, when we do a retro query does that query also have to be apart of the permanent record?    

    thank you!

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