copy and pasted radiology reports
Wondering what other hospitals are doing with copy and pasted radiology reports in notes and taking diagnoses from them. We are trying to do education to say that you need to query the provider for clinical significance and the provider should note it in their progress notes narrative and/or assessment and plan what the full circle of care was meaning treatment and plan to show clinical significance.
Thoughts??
Thoughts??
Comments
Best Regards,
Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org
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Request for Clarification or Confirmation Of Radiology Findings
Dear Physician/PA/NP: __________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.
The Radiologist has identified on ________________ (DATE) in the __________________________ (TYPE OF EXAM)
The Diagnosis: _____________________________
Please validate this diagnosis.
CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________
Physician/PA/NP Response:
CONFIRMATION:
0 I concur with the Radiologist Findings
0 I do not concur with the Radiologist Findings
0 Cannot be determined
CLARIFICATION of findings: Please document any SPECIFIC diagnosis or pathology associated with these Radiology findings.
0 Diagnosis/Pathology: ______________________________________________
0 No clinical significance
0 Cannot be determined
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
PE
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org