QUERY PROCESS FOR ALL COMPUTERIZED DOCUMENTATION

lsipos@monument.healthlsipos@monument.health
in CDI Talk Archive
Hello!
Help!
Our institution is currently using a "physical chart"- including hand-written progress notes for the physicians. Currently this is where the CDS leave the "paper" queries for the doctors.
We are working towards an all computerized documentation process-including the physician progress notes. However, due to this, the providers will then, no longer have a reason to be in the "physical chart" which is where we place our query to notify them of the documentation clarification needed! As good as many of our physicians are, there are just too many who would not go into the old physical chart to look for query if they are using computerized charting.
Does anyone have any ideas for how to notify the physicians of a query-or systems they are currently using in their institutions to notify the physicians there is a pending query? We use MEDITECH in our facility and with the building of pDOC for provider computerized progress notes it would be nice to be able to "build this in as we go". Can anyone tell me how they use, or process the queries in an all computerized world? Thanks!
Suggestions??????

Juli Bovard RN
Clinical Documentation Specialist
Clinical Effectiveness/Clinical Quality
Rapid City Regional Hospital
719-4390 (work)
786-2677 (cell)
"No Limit to Better......"



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Comments

  • dvitalone1dvitalone1
    edited May 2016
    Your EHR should have a way to do electronic system





  • robert.hodges2robert.hodges2
    edited May 2016
    I don't use Meditech, but we have a fully electronic record. I use
    either telephone/pager to contact providers or use secure email.



    I would check with your system administrators and find out what methods
    are available to you.



    Adapt and overcome!



    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



    "We are dealing with Veterans, not procedures; With their problems, not
    ours." --General Omar Bradley



  • cturveycturvey
    edited May 2016
    The client site I am currently working is an all EMR facility. They send the MD queries via intranet e-mail and thru eD-H electronically. The response is tremendous. It is somewhat time consuming as each query is developed independently but the basic format is the same. As for long as the clinical criteria/indicators are included and the queries are not leading it works.


    [cid:image001.gif@01CC4D22.ACF66F00]







    Carol Turvey RN, BSN, CPHQ, CCDS
    IBP Clinical Documentation Program Director

    401 N. Michigan Avenue
    Suite 2700
    Chicago, IL 60611

    cturvey@accretivehealth.com
    www.accretivehealth.com



    mobile:
    fax:


    (484) 892-9086
    (734) 847-1778








  • toni.stastnytoni.stastny
    What software does your facility use?
  • ssalinasssalinas
    edited May 2016
    Where do you physically place the query with a fully electronic record?


  • robert.hodges2robert.hodges2
    edited May 2016
    Our queries are not part of the medical record by directive, currently
    we use a query tracking tool in the coding software for follow up and
    reporting, all of which is still pretty new to us. We have standard
    queries that are used by myself and the coders so we have consistency in
    our presentation.



    I hope that answers your questions.



    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



    "We are dealing with Veterans, not procedures; With their problems, not
    ours." --General Omar Bradley



  • nursronnamnursronnam
    My previous facility had Meditech. I was told they did not have a way to do electronic queries within there system.

    Ronna Mahlen, RN, BSN, CCDS
    Senior Clinical Documentation Improvement Coordinator
    Valley Medical Center
    Renton, Washington
  • Unknown
    edited May 2016
    Juli,



    I also use Meditech and we are all computerized at this point. If you
    send me your email address, I can send you some screen shots of the
    message system that I currently use. I find it works very well.





    Lisa McLuckie, RN

    Clinical Documentation Specialist

    Wooster Community Hospital

    lmcluckie@wchosp.org



  • ssalinasssalinas
    edited May 2016
    We have been told the same but I am hoping some ingenious facility has found a way of doing it in MT. I am asking our IT and HIM staff to investigate to see if a word document could be inserted in Other Reports for a physician to edit and sign since our queries are part of the legal record. Problem is once it there, there is no way to remove it.....

  • ddraizeddraize
    edited May 2016
    We have just converted to Meditech 6.0 and will be implementing complete EMR in the next phase. When I asked about queries the rep was unsure if they had this available. I would love if you could email me some screen shots as well. Thanks

    Diane Draize RN, CPUR,CCDS
    Clinical Documentation Specialist

    Ministry Door County Medical Center
    diane.draize@ministryhealth.org
    920-743-5566 ex 3143

    We earn trust by working together as One Ministry to keep PATIENTS FIRST in everything we do






  • cturveycturvey
    edited May 2016
    It is not physically placed anywhere because it is electronically submitted.





  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    Lisa
    That would be great! Thanks!

    Juli Bovard RN
    Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    719-4390 (work)
    786-2677 (cell)
    "No Limit to Better......"
    jbovard@regionalhealth.com



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