Verbal queries
Hello all,
I did a search but did not find anything about verbal queries. Wondering how you track these? How do you audit query compliance? Thanks for any and all processes that you follow.
Ronna Mahlen, RN, BSN, C-CDS
Valley Medical Center
Renton, WA 98055
425-228-3440 x 3610
I did a search but did not find anything about verbal queries. Wondering how you track these? How do you audit query compliance? Thanks for any and all processes that you follow.
Ronna Mahlen, RN, BSN, C-CDS
Valley Medical Center
Renton, WA 98055
425-228-3440 x 3610
Comments
Sharon Cole, RN, CCDS
Case Management
254.751.4256
srcole@phn-waco.org
"Verbal queries will have a written summary recorded of the conversation as soon as practical following the query"
"Verbal queries are acceptable and may either be the result of a fortuitous encounter with the attending (where the written query was already submitted but not viewed) or may be a result of attempting to obtain an answer to a written query where the medical staff had not yet responded"
The intent is that the written summary of the verbal query is recorded and stored in the same manner as the written query. The content should also be the same (ie, include the clinical indicators / documentation quotes discussed, the question & options posed and the physician's response to the question).
With this type of documentation, allows essentially the same audit process and standards to be applied.
Don
said, frequently our verbal queries are stemming from an original
written query. Either way, our clinical findings, what prompted the
query is typed in to the program as the basis for the query. The report
I run will identify what form the query was in for tally.
Donna
Donna Kent, RN, BSN, CCDS
Manager, Clinical Documentation Integrity Program
Clinical Quality and Accreditation
Torrance Memorial Medical Center
ph.:310 784-6884 fax:310 784-6899
donna.kent@tmmc.com
Remember mission and purpose over business as usual...
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
Most of us do not need lecturing, but the kind, supportive language of your articles and blog postings.
Thanks for the reminder about the overall purpose of CDI.
Mark N. Dominesey, RN, BSN, MBA, CCDS
We want a complete and thoroughly documented medical reecord. However, there must be some accountability of work and productvity. And for those who count the $$ and give us additional positions, $$ for educational resources, we can show them how we have impacted the bottom line as an additional perk. And this done by simply asking - compliantly - to document what is already present in the chart and being treated.
NBrunson, RHIA,CCDS
and accounted for. Beyond a certain point, the reliability of data
collection is going to suffer. (As a complete data geek, I continually
need to be reminded by my staff to KISS -- keep it simple -- and we then
tend to get key data accurately).
The data I report up to executives does reflect non-financial activity
of our group. In addition, I have explicitly included expectations
about formal and informal education with providers as part of the matrix
which drives CDS evaluations.
Also, the simple process of discussing what the issue is (about the
documentation vs clinical picture) inherently involved education and I
presume that as a background factor for any verbal query. But as was
pointed out, there is not an active accounting of physician education.
(I do intend on replying to the blog posting from Glenn, but as well
done as that post was, I want to put up a thoughtful response.)
Don
However, given any coding system 'rewards' more specific coding, we have found that improvement in our O/E ratios is logically accompanied by valid increase in our CMI. This is inevitable.
Each query form we use cites 'evidence-based' criteria (example: Surviving Sepsis) as a permanent part of the record, and we ask the MD to determine if the MD-approved criteria is met, not met, unable to determine, some other condition, and so forth.
Therefore, I do believe such query forms serve to educate the staff in regards to terminology, documentation, coding, Core Measures, O/E, and so forth.
However, it is not practice to educate a particular MD each time we leave a query in a chart - but, I believe our process is 'educational'. As Don stated, we would all appreciate data, but entering data has costs - at this time, we have 2.9 FTE for over 1,000 beds, and we are very strategic in how we focus our efforts.
Paul Evans, RHIA, CCS, CCS-P
Supervisor, Clinical Documentation Integrity, Quality Department
California Pacific Medical Center
2351 Clay #243
San Francisco, CA 94115
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
Cindy
Carmella
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
“Patriotism is easy to understand in America; it means looking out for yourself by looking out for your country" Calvin Coolidge
We started a new process about a week ago with our Hospitalist group. The Director of Case Management and I meet with the hospitalists on service each morning to discuss each patients case and the plan, etc.. My boss and Director of Medical Records periodically sits in on these meetings. Today she was present and asked if I logged verbal queries for each of the patients I discussed with the hospitalist in regards to clinical documentation improvement, clarification, etc. Currently I would just log it in our CDI program as a verbal query. Does anyone currently log verbal queries in a query form by stating what was discussed and the physicians response being documented by myself per the physician (rather than the physician choosing an answer by placing an X, (like the written queries) and then have the physician electronically sign it? We are currently paperless with all of our queries. How does one go about capturing this information, without then querying the physician again for the information and at the same time remain compliant with the AHIMA guidelines for a query?
(EX:: Physician stated the patient had CHF exacerbation with Pulmonary Edema. I asked the physician for the acuity and he said it was Acute. How do I capture this increased specificity if it is not currently documented, but the physician specified the acuity verbally? Thank you!
Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center
We are hybrid so we have in the past actually made up a Verbal Query form and entered the query into our software making sure we documented that a verbal query was given and thus and such was the answer.
As of late we only enter it into the software with a note of clarification.
Is there a way you could issue the query electronically but not actually assigned it to the physician? Is there a deficiency assigned when you issue electronically? If there is a way to issue but not count against the physician that may be an option. I would make sure you have a policy/procedure in place.
Or...there's always the Spreadsheet...
N.Brunson, RHIA,CDIP,CCDS
Shelia
NTB