EPIC in-basket queries

Had a different denial today... They are stating that Epic In-Basket queries are not compliant stating the following: -"Dr. X answered the clinical documentation clarification note in an email format" -"Based upon published recommendations provided in Journal of AHIMA, it is determined that query presented does not meet the standards as indicated below.... "Physician signature/authentication" -"Every entry is required to have a date and signature by the responsible party making the entry"

I will argue that the response does note their name and date but is that the same as a signature? I am sure they are going to say no.

What are your thoughts? What would your defense be?

Thank you!



  • If you have a facility policy for what constitutes an acceptable query format and response I would cite that.

  • Granted this is my PERSONAL opinion, but I think a query should be in the form of a progress note or some other note filed in the legal medical record...the patient’s record, rather than kept as type of business documents. Having said that, AHIMA does not make this stipulation.

    In my view, an email can only be sent by one recipient and it does have a date/time stamp. If I were in your situation, I would try to get help from my compliance department with input from legal counsel. They should be able to cite something formal regarding the weight of email responses. And as has been stated above, use of e-mail should be covered in your formal facility policy.

    P. Evans, RHIA, CCDS

  • AHIMA Best Practice Brief states that ‘ideally the response is filed IN the medical record’. But, it goes on to stated ‘organizational policies should address if the query is part of the record OR stored as a separate business record.

  • Great idea, I will definitely consult compliance. Thank you all for your help. I agree that moving them to a progress note is probably our best long term option.

  • Take a look at the 2019 Best Practice published by AHIMA for guidance. It states we are ‘encouraged’ to have robust guidelines in place that define the contents of the health record....it makes reference to a compliant query properly answered and authenticated..

    Also check with you Medical Staff By Laws as to what constitutes a legal entry.

    Best Wishes...


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