Queries... preprinted vs free hand... what do you use?

arsusott@msn.comarsusott@msn.com
in CDI Talk Archive
We will go to an electronic record 10/12 and it hasn't been decided if it will be completely electronic or if the progress notes will still be paper thus making our queries still paper. We are trying to start thinking about our process as we move toward the electronic record. The question I have is do you use only preprinted queries or do you free hand your queries? In our facility we free hand most queries. Next, are your queries part of the permanent record or do you ask all queries be answered in a progress note? Are your queries used by the coders to pose a retroquery?

Thanks in advance for any responses!

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    We just implemented electronic query tracking here. We are using query templates, but include a "general" query form for those that don't fall into one of the templates. I've also worked with a national group at the VA which has developed standard language for queries as well as 40 standardized query forms and a practice brief on provider queries. The templates were developed to ensure that queries are not leading and to assist coders who may not have clinical backgrounds to identify possible issues. The other reason is to give providers the same look on all queries so they will learn what is requested and needed by coding when they see a query. The overall goal of course is to improve provider documentation.

    Our queries are not part of the medical record and we do require a note or addendum to a note as a response. Both coders here and I use the same queries for consistency.

    Hope this helps.

    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
     
    P: 989-497-2500 x13101
    F: 989-321-4912
    E: Robert.Hodges2@va.gov
     
    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens

  • kmckaigkmckaig
    edited May 2016
    We currently have an EMR hybrid. However, we do all of our queries in "Message Center" in the EMR. We currently free hand but have plans to do pre-printed queries. Our queries are not part of the record although, they are accessible if we need them.

    Hope this helps,
    Karen


    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
  • cbarnescbarnes
    edited May 2016
    Paper queries, free-hand w/ a standard format Coders use a free hand that each writes of their own accord Answered in progress notes and DC summary
  • paxnerospaxneros
    edited May 2016
    We have both pre-printed and we may free-hand queries. Our Queries are Word documents that we may personalize for each patient if needed.

    We use a hybrid record at this time and place paper queries in progress notes.

    We want our physicians to document in the medical record so our CDI queries are not part of the permanent medical record.

    Our post discharge queries (issued by coding dept) are a part of the permanent medical record. If a CDI query was not answered on the floor, and the coder still needs that information, they will formulate their own query which is then scanned into the medical record. They may use the same format as our queries (because we allhave access to the Word doucuments) or formulate their own.

    NBrunson, RHIA,CCDS
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