Queries as Part of the Medical record
I am seeking assistance with a written policy around queries being part of the medical record. Our organization has never been in favor of that practice but I am tasked with updating that policy and changing that practice. Does anyone have a policy they would be willing to share? In addition my question is: does this include ALL queries? Inpatient/outpatient, requests for OP note addendums?
Thank you,
Dawn
Comments
Hi Dawn,
We use the latest Query Guidelines put forth by AHIMA/ACDIS in our policy. Planning to update as soon as the latest one is released. The CDIS queries are part of the business record only while the coder queries are part of the permanent record.
Thank you so much for your response. Interesting distinction. Electronically how do you delineate between business record and permanent medical record? I don't understand the difference in practice. Appreciate the follow-up, Dawn