Compliant Queries
Good morning,
I am not a fan of the query templates used at the facility where I work. There is a lot of bolded text, underlined text, use of wording such as "infectious clinical indicators" and "above abnormalities". I feel this is leading...what are your thoughts?
Thank you,
Pamela Anderson
CDI Team Lead
Comments
Hi Pamela,
Refering to the Query Practice Brief below. It states:
Question: Is it allowable to include definitions within a query? For instance, a query for afib specification including definitions for the type of atrial fib? Or a query for CKD staging including the ranges of stage differentiation?
Answer: Including such information on a query is common. This practice allows providers ease in access to organizationally developed diagnostic criteria or industry evidence-based guidelines. This practice is not thought to be leading. The information should be provided without any indication of choice, meaning the information should not highlight, bold, or indicate a desired answer.
Question: Is it compliant to highlight or bold important information or clinical criteria in a query?
Answer: It is best practice not to highlight any information within the query that could be construed as leading, and highlighting should never be used within the option choices of a query.
How to Query
Regardless of format, method, or technology used, queries serve the purpose of supporting clear and consistent documentation of diagnoses being monitored and treated during a patient’s healthcare encounter or the specific procedure performed. A query must adhere to compliant, non-leading standards, permitting the provider to unbiasedly respond with a specific diagnosis or procedure. References to reimbursement must not occur. All relevant diagnoses, lab findings, diagnostic studies, procedures, etc. which illuminate the need for a query should be noted and cited as to the location within the medical record. A query should not direct (lead) the provider to document a specific response (e.g., highlighting, bolding, underlining, italics, using a yes/no format to obtain a new diagnosis). It is non-compliant to continue sending the same query to the same or multiple providers until a desired response is received.
Queries should be concise and provide direct information obtained from the medical record without influence. It may be that you need to meet with leadership, and the team to discuss the query brief, and evaluation of current process.
Hope that helps!