Use of screenshots in queries
I am wondering how common the use of screenshots of documentation are in queries. I have never used screenshots when writing queries however currently seeing some CDSs use them in their queries. I can find no evidence that screenshots are bad but have always been instructed that they can contain extraneous and irrelevant information that could make the query non-complaint. What is the consensus of CDI leadership across the country? Guidelines for Achieving a Compliant Query Practice(2019 Update) does not specifically address the issue so I am curious how others are approaching it, if at all.
Screen shots are a part of the legal record, and often, a screen shot of provider documentation provides excellent citations relevant for inclusion in a query; I also make screen shots of labs, etc, in a query. I take care to only include citations that are relevant. I argue that using a portion of the actual charted material strengthens the compliance of the query.
Paul Evans, RHIA, CCDS
I want to clarify the issue that I have found with screen shots. The screen shots in queries I have reviewed have contained extraneous information to the point the author highlighted the information they wanted the provider to review within the screen shot. This, to me is now "leading" the provider. So it isn't the screen shot itself but the irrelevant information captured in the screen shot that leads to highlighting the information that is relevant to the query, to me that makes the query non-compliant. So is it best practice to avoid screen shots altogether?
If one cites and uses only compliant info in the ‘screen shot’, I do not personally think it is a problem at all. I agree a query must be concise, clear, and only cite relevant references. The issue you describe seems to be the construction (wording) of the query rather than the use of screen shots.
I use screen shots of wound pictures in my pressure injury queries and labs and vital signs to show trends for queries for things like acute respiratory failure, ABLA etc.
I will copy and paste quotes from a document to use in a query, particularly when there are discrepancies in documentation.
I think as long as your are careful thoughtful in what you screen shot, it can be very helpful.