Stickers as queries

nursronnam

Does anyone out there use stickers for the chart as a query? We have made stickers for Nutritional assessment that we place in the chart after the dietician does his/her assessment. It shows

Patient meets criteria for:
Overweight (BMI 25-29)________
Obesity (BMI 30-39.9)_________
Morbid Obesity (BMI > 40)_____
Morbid Obesity 100 lbs
over IBW or 100% > IBW ______

Clinician Signature ______________

Physician signature ______________

We input the BMI and leave it on a progress note for the MD to sign.

How do you guys feel about this? Do you think it is appropriate?
Would you use something like this for CHF or CKD?

Love to here your thoughts

Ronna

Ronna Mahlen RN, BSN | Manager of Clinical Documentation | Clinical Documentation |Overlake Hospital Medical Center |1035 116th Ave NE Bellevue WA 98004
425-467-3811 Phone | 425-941-0502 Cell| Ronna.Mahlen@overlakehospital.org

Unknown

We use preprinted queries from our consultant, Navigant. They are about
4x6 post it notes and we place the query on a blank clinical documentation
form so they show past the edge of the page in the medical record. They
are different colored paper and the titled like CHF, CKD, abnormal
nutrition etc. This format has worked well for us. The doctor addresses the
query in their progress note, not on the query itself. The query has a
small box to check if they disagree but they rarely use it .


Kim Beard
Clinical Documentation Specialist

Unknown

We do not use sticker but I do have 2 query forms I use with this same information.

one for a diagnosis of (obesity, overweight, morbid) that do not line up with BMI
and one for a documented BMI (usually by dietian) but no diagnosis (used


Charlene

dallend@einstein.edu

I think you should give them the option to document that they disagree and other (where they can document their own diagnosis). I usually try to document if they patient has any comorbid conditions such as OSA, etc.

sbeatty

We used 4x6 post-it queries for a few years. Our challenge was the MD
who would remove it because it wasn't addressed to him, and would stick
it to the opened upper half of the chart. It would then be missed by the
next physician to whom it was addressed. They also tended to migrate to
the counter in the nurses' station and then get left out of the chart.
We didn't have patient labels on them, so we'd have to back track
through our carbons of worksheets to see who on that unit had that type
of query. We originally had consultant-provided full page queries. These
were routinely buried by night shift staff who stuffed charts, and by
day shift secretaries filing dictations. We've now come full circle,
back to full page queries. However, after we type up our request, we put
it on top of the progress note section, but fold the paper to the side
much as a doctor does an order sheet with new orders. Along the edge
that sticks out, we write CLARIFY. That's what the 4x6 post-its had said
along the protruding edge. We use highlighters to write CLARIFY on the
query, and to hit key findings/treatments we've noted on the query. Our
doctors don't want to read any more than absolutely necessary. Once they
see the findings and treatments, they know we want a diagnosis with as
much specificity as possible. They know what to do-if they will! Once
scanned, the highlighter doesn't show up and all of the text appears as
typed. We also sound the post-it queries labor intensive for those staff
in HI who scanned. They had to mount them and it decreased productivity.



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Sandy Beatty, RN, BSN, C-CDI

Clinical Documentation Specialist

Columbus Regional Hospital

Columbus, IN

(812) 376-5652

sbeatty@crh.org



"The most important thing in communication is to hear what isn't being
said." Peter F. Drucker

dog

No stickers. My queries are printed on yellow paper (our progress notes are blue) and placed in front of the most recent progress note. Unfortunately, if a few other disciplines document before my target physician, my query can get pushed to the back.

I don't know if I like the idea of stickers or checkoff boxes. Probably because of my nursing experience with checkbox forms such as medication reconciliation--the doctors don't read them; they either ignore them or check off everything.

Renee

Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital

dallend@einstein.edu

We do not use stickers. Our queries are full page and also placed in front of the most recent progress note. We do place a flag on ours "Please review" that sticks out past the end of the page. Our forms also get moved sometimes or other notes move it back further in the chart - Our physicians know if they see the the Please Review flag that they need to take a look at the paper that is attached to it. It's not perfect but it works most of the time.
I don't like stickers - they can fall off. Our permanent forms do have check boxes with multiple choices including other and unable to determine. Our physicians seem to like these forms and are much more compliant with the permanent forms than our adhoc query forms. We are in the process of developing add'l permanent query forms since we have so much success with them.

lspryszak

From "Managing an Effective Query Process", AHIMA, October 2008

"It is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded. The preferred formats for capturing the query include facility-approved query form, facsimile transmission, electronic communication on secure e-mail, or secure IT messaging system."

nursronnam

I guess I was not clear. These are not sticky notes, they are stickers that are stuck onto a progress note. They do not come off.

Ronna