query language for radiology results

mistercw

CDI team members at my facility (Calif Pacific Med Ctr in San Francisco) sometimes use radiology results as the basis for a physician query. For example, if a post-op chest x-ray shows atelectasis by a radiologists's reading, we would like the attending physician to document whether the atelectasis is clinically significant. Another example would be asking the attending doc to document cerebral edema seen on a stroke victim's MRI. The idea is to get into the medical record patient complications/comorbidities demonstrated via radiology.
Here's the issue. I print out the radiologists's reading and attach it to a query on which I write out what aspect of the result I'd like the physician to address. But my colleagues think that by asking for comment on a specific diagnosis (ex. cerebral edema) mentioned only by the radiologist I'm leading the attending by introducing a new potential diagnosis. They say that since the radiologist's reading alone doesn't "count" toward diagnoses, in effect I'm tellling the attending what to diagnose (which is a no-no).
Any commenst/thoughts on this problem?

lspryszak

I absolutely would query for these diagnoses when warranted: extend length-of-stay, use additional resources (for example, ICP monitoring, drainage or evacuation of a cerebral hemorrhage, etc.) and I always cite the MRI/CT findings because the provider sees the report and thinks that he/she doesn't need to re-write it.

Anyone with a midline shift, compression of the ventricles, etcetera almost always has either/both cerebral edema or compression of the brain (which are both severity drivers) - and these diagnoses are almost never documented or coded.

You are on the right track.

robert.hodges2

Yes, but be very careful how you word the query. I ask for "clinical significance if any" on the findings or reading. It's up to the attending to make that determination and how that report impacts their medical decision making.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
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melanie.halpern

Suggested verbiage: "If possible, please render an opinion concerning the radiology report of XXXX by documenting the clinical significance of these findings in the medical record." Melanie
Sent from my Verizon Wireless BlackBerry

judithbates

Thanks for this dialogue. Really good information to reinforce the importance of capturing these "clinically significant" conditions


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

katysuegood@gmail.com

I do query for these dx, especially cerebral edema and brain compression.
However, I have a question. For those who state that they are querying for "clinical significance", do are you wording it in a way that ensures that you get both the significance AND the actual dx.
I am concerned that if I presented the radiology data and then asked for the clinical significance I would only get how the dx (brain compression for example) is significant, but the provider may not actually document that the patient has brain compression since it is listed on the query and in the radiology report.
Currently, I present the indicators/report and then just ask waht medical condition is being treated. This is not always effective, but I haven't thought of a great way to improve it.

FTR- our queries are a part of the medical record and often the providers to not carry diagnoses through into the progress notes after they answer the query although I encourage them to do so.

Thanks,
Katy Good

catladyrn

I'm pretty sure I borrowed this language from another poster as there was an earlier discussion on this topic, but this is mine:

"If any of the following are appropriate to describe the results of the radiology report and have clinical significance for the patient, please further specify in the progress notes the condition and its clinical significance" followed by several choices.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center