Pressure ulcer query

Good morning,

We are having a discussion at my facility about the best way to query a physician when the documentation in the medical record of the pressure ulcer, stage, and site are only present within the nursing notes.  Would a yes, no, other, or not applicable be a compliant way to pose this question?  We have seen similar examples of compliant queries asked in this manner regarding pathology and radiology, however that information is provider based.  Perhaps that doesn't matter.

Thank you in advance,

Larissa Stein, RHIT, CCS, CCDS

Comments

  • We send a query to the provider documenting the wound care nurse's assessment of site, type  ulcer, stage and recommended treatment (which is ordered) and ask if they agree with the wound care nurses assessment of "stage 3 decubitus ulcer to coccyx" for example treated with daily dressing changes and barrier cream, etc. There are usually photos in the nursing notes we referenced as well. A simple agree with the above wound care nurse assessment and findings, disagree, other, and the ever present, clinically unable to determine as choices. 
  • Hi Larissa,  

    According to the AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2016 Update) "..In addition to present on admission (POA) determinations, yes/no queries may be
    utilized under the following circumstances:
    - Substantiating or further specifying a diagnosis that is already present in the health record (i.e., findings in
    pathology, radiology, and other diagnostic reports) with interpretation by a physician
    - Establishing a cause and effect relationship between documented conditions such as manifestation/etiology,
    complications, and conditions/diagnostic findings (i.e., hypertension and congestive heart failure, diabetes
    mellitus and chronic kidney disease)
    -Resolving conflicting documentation from multiple practitioners.."

    Regarding your question if a yes/no query is appropriate for wound care nursing notes, then according to the guideline, it would not be appropriate.  The wording in the guideline of  "interpretation by a physician" is what would exclude the wound care nursing notes from being compliant with the yes/no query guideline.    

    I would also caution using agree or disagree because of its similar meaning to yes or no.   

    Thanks, have a great day everyone!
  • A query could include the wound description/location and treatment - asking if there is a diagnosis associated with the evaluation/treatment (i.e. wound care nurse consult, pressure relieving surfaces, frequent repositioning, dressings/site care).
    If the provider identifies the wound as a Pressure Injury then staging can come from Nurse or Physician documentation.
  • edited January 2018
    Some providers are pulling the LDA note into their progress notes (copy/paste) along with radiology and other information and not commenting on it further, just copying it into the note.  What are your thoughts on that?

    "Substantiating or further specifying a diagnosis that is already present in the health record (i.e., findings in pathology, radiology, and other diagnostic reports) with interpretation by a physician.) AHIMA/ACDIS Guidelines for Achieving a Compliant Query Practice (2016 Update) 


    Larissa
  • Hi Larissa, 
    My thought on that is that it still is not considered interpretation by a physician if the physician has not called out the diagnosis by him or herself.   Strictly copy and pasting radiology reports or nursing notes  to a progress note does not equate to the physician providing interpretation of that given diagnosis.  Oh the joys of electronic medical records.  
  • I agree!  Thank you for your comments :) 

  • Good Morning, I was wondering if there was any follow up to this discussion or recommendations for writing a query when the patient has a pressure ulcer and Wound Care has evaluated the patient with documentation of the ulcer, but there is no documentation of a pressure ulcer in the record by the provider? Per the Guidelines for Achieving a Complaint Query Practice 2019 Update - the Yes/No query is no longer valid which is the type of query we used for this. We are looking for a new way to query this.

    Multiple Choice Query? Your reasonable options would include the site of the ulcer, other, unable to determine.

    - Q: Based on your medical judgment and review of the clinical indicators below, can you please select the most appropriate diagnosis? 

    A: Pressure ulcer on coccyx as documented in wound care consult, Other explanation of clinical findings, Clinically unable to determine

    Open Ended Query? No reasonable options listed

    - Q: Based on your medical judgment and review of the clinical indicators below, can you please assign a diagnosis to the skin condition that is being treated:?


    Also, what format for a query is used when the patient has multiple pressure ulcers, has been evaluated by Wound Care with supporting documentation, but NO physician documentation of the ulcers in the record?

     - Do you send one query for each site?

    - Do you send one query that includes MULTIPLE sites, with multiple choice options, each option is one of ulcer sites and the physician with choose all that apply?


    Thanks so much!


  • For a compliant pressure ulcer query should a NOT POA also be listed as a multiple choice?
    Thanks, Debbie
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