Auditing Tools for Physician Queries

dbutler

Was hoping that folks would be willing to share any tools that may be in use to audit physician queries -- whether those queries are presented by Clinical Documentation Specialists or by Coding Professionals, and whether presented concurrently or post discharge/retrospectively.

Any focus of audit is relevant to my interest.

I had been working on a writing project with ACDIS / HCPRO on auditing of queries for CDI, and was looking for some examples that either could be offered or be used as a basis to develop an example.

Thanks,
Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

robert.hodges2

I received this one from a MACDIS meeting email here in Michigan. I kind of like it.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

nursronnam

Here is what we came up with. Would love to have feedback from anyone or everyone.

judithbates

I love it!!! Really I think it has all the elements you need for auditing. Even for a person who is new to the program, it highlights the guidelines for formulating your query. GOOD JOB!!!

Judi Bates RN, BSN, CCDS
CDI Specialist
856-757-3161
Beeper 66x2906

jolene.file

I think it is very well done.

Unknown

Thank you, thank you, I agree - sharing it to our team to use as a reminder for checking their own queries at the front end.

Linnea Thennes, RN, BS, CCDS
Supervisor, Clinical Documentation Improvement
Centegra Health System
815. 759-8193
lthennes@centegra.com

dbutler

Thanks to: Robert, Traci & third person for responding.

Really, all 3 have something different to offer and each of the forms seem to me to offer real value for any organization.
The foremost thing is that an organized audit takes place, and then of course that the audit occurs with a reasonably good tool (carefully developed to target the information desired) and finally the gathered information is used for improvement activities.

I understand there will be a white paper forthcoming in July on Auditing for anyone that might be interested
These tools were very helpful to me as I was looking at developing a tool to start with my organization & to offer as a sample to go along with the white paper.

Thanks again!
Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com

[Deleted User]

Thanks for posting Don and thanks to those who responded. What do you all think about posting these contributions to the Forms & Tools Library? Would that be okay with those of you who volunteered your materials?