Query Process Question #2...
I'm interested in how others handle queries generated by another CDS that either move to your floor, or was generated on the weekend by the weekend cover person, or was generated by someone who was covering for someone on vacation.
Scenario -
CDS covers all assignments on weekends. Reviews all admissions, generated Queries on all floors.
CDS comes in on Monday to review their assignment, reviews queries (*which are not a permanent part of the chart*) initiated by weekend CDS - and finds that MD has documented his response on the query - not in the record where it should be documented.
CDS which covers that assignment initiates another query - in additiont to the one on the chart - reminding MD documentation should be made within the Medical Record. Physician then makes documenation within the record, coder codes the chart with documentation.
- For those who do weekend coverage, do you follow the queries you initiated to other floors? Or do you let the Assigned CDS follow the query when they return?
- How do you credit queries?
- If another CDS assists in some way to get your query answered do you both share in the credit - for statistical purposes? (in the example above - if the CDS had not reminded the physician that the query was not a permanent part of the chart and the docuementation needed to be made within the chart - the coder would not have been able to code the information and the query would have been "mute".)
Another example might be when reviewing a concurrent record on a chart which had a query generated by another CDS - which had no response - and calling the physician's attention to the query resulting in him documenting the information.
Thank you in advance for your wisdom and experience.
N. Brunson, RHIA, CCDS
Scenario -
CDS covers all assignments on weekends. Reviews all admissions, generated Queries on all floors.
CDS comes in on Monday to review their assignment, reviews queries (*which are not a permanent part of the chart*) initiated by weekend CDS - and finds that MD has documented his response on the query - not in the record where it should be documented.
CDS which covers that assignment initiates another query - in additiont to the one on the chart - reminding MD documentation should be made within the Medical Record. Physician then makes documenation within the record, coder codes the chart with documentation.
- For those who do weekend coverage, do you follow the queries you initiated to other floors? Or do you let the Assigned CDS follow the query when they return?
- How do you credit queries?
- If another CDS assists in some way to get your query answered do you both share in the credit - for statistical purposes? (in the example above - if the CDS had not reminded the physician that the query was not a permanent part of the chart and the docuementation needed to be made within the chart - the coder would not have been able to code the information and the query would have been "mute".)
Another example might be when reviewing a concurrent record on a chart which had a query generated by another CDS - which had no response - and calling the physician's attention to the query resulting in him documenting the information.
Thank you in advance for your wisdom and experience.
N. Brunson, RHIA, CCDS
Comments
Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906
AMY
Now that we are not floor specific, we follow thru out house as pt travels.
Karen McKaig, BSN, RN, CCM, CPUR
Case Manager
Clinical Documentation Specialist
Baxter Regional Medical Center
Mountain Home, AR 72653
870-508-1499
kmckaig@baxterregional.org