queries as part of the medical record

sbeattysbeatty
in CDI Talk Archive
I know this has been discussed many times, but I wanted to get a feel whether organizations are changing their policy on physician queries given the implementation of the auditors-RAC, MAC, ZPIC, CERT, etc.

We have a hybrid record, moving to all electronic next June. In the meantime, our queries are paper and are not part of the medical record. Because we use diagnostic criteria approved by the medical staff, and cite the clinical findings and treatments for which we are asking if a diagnosis is appropriate, we're now wondering if we should change our policy to have queries be part of the medical record. Our hypothesis is that the RAC denials and backend time spent on RAC appeals would decrease if we had the query in the record when it is sent. I'm interested in the group's thoughts on this. Thanks in advance for your input.

Sandy Beatty
Columbus Regional Hospital

Comments

  • robert.hodges2robert.hodges2
    edited May 2016
    Still not part of the medical record here, but we have a query tracking system so can see if a query was done related to a particular encounter if needed.

    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

  • cynthia.a.goeweycynthia.a.goewey
    edited May 2016
    We have an electronic medical record. We send our queries electronically. They are not part of the medical record.
    Cindy

  • kmckaigkmckaig
    edited May 2016
    We have a hybrid record but send queries electronically. Not part of record.




    Karen McKaig, BSN, RN, CCM, CPUR, CCDS
    Case Manager
    Clinical Documentation Specialist
    Baxter Regional Medical Center
    Mountain Home, AR 72653
    870-508-1499
    kmckaig@baxterregional.org


  • fishdl@shands.ufl.edufishdl@shands.ufl.edu
    edited May 2016
    When we went live with our EHR (EPIC) in May, our queries became a
    permanent part of the medical record. The CDI Team now creates all the
    queries - both concurrent, as well as, post-discharge.

    Donna Fisher, CCS, CCDS
    CDI Coordinator
    Shands at the University of Florida


  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    We have a hybrid record - progress notes are still paper though. CHF, anemia, CKD, Debridement, Skin ulcer and POA form are part of the permanent record. All other queries request the MD document the response in the progress note - we do track our queries in an electronic database so we can provide the information if needed.
    All post discharge queries are completed electronically as our charts are scanned after discharge.

  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    We currently utilize Meditech and also, have a paper chart. However coming in the next several months, pDOC (physician computerized documentation) will be implemented. Once, the physician is utilizing pDOC-(and there would be no need for the provider to be in the “paper chart”), we were worried about our paper queries and the response rate-knowing the physicians would not go out of their way to look in a chart for the query. We have decided to make our queries a permanent part of the medical record, and have written 18 queries with a “generic” form as well-for those queries that do not fall into a specific category. Our only issue now is that we are struggling with how to notify the provider of their query in the Meditech System once they are documenting using pDOC.
    We DO feel a greater strength, and satisfaction by standardizing the queries and making them a permanent part of the record!

  • cfowlercfowler
    edited May 2016
    What system/how are you completing the queries electronically once they are scanned?

    Carla D. Fowler, RN MBA
    Director Case Management/CDI
    Colquitt Regional Medical Center
    3131 South Main Street
    Moultrie, GA 31788
    V 229-891-9363
    cfowler2@colquittregional.com

  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    AccessAnyware (Streamline Health) is where our scanned records are maintained.

  • cfowlercfowler
    edited May 2016
    Are your physicians able to complete (document electronic answers on the query) and sign electronically?
    We can do the signature piece through our scanning system/deficiency system but continue to struggle with how to get the query completed electronically. (how do they get the answers on the queries)
    c

    Carla D. Fowler, RN MBA
    Director Case Management/CDI
    Colquitt Regional Medical Center
    3131 South Main Street
    Moultrie, GA 31788
    V 229-891-9363
    cfowler2@colquittregional.com

  • dallend@einstein.edudallend@einstein.edu
    edited May 2016

    They add an addendum note electronically in the system. We enter the query as a deficiency.

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