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
Our coder queries are generated and sent directly through the EMR (hence it will always be there). The CDI queries are done either verbally or by email. A note is then posted to the chart that a query has been sent (or discussed) but does not contain the actual query. These queries are uploaded to a department folder (rev cycle) for viewing later if needed. We are a small acute care hospital and we do not have any extra CDI software that isn't already imbedded in the Solventum encoder program the coders use. If you have CDI software, you could probably make the decision to send the queries through that and keep it as part of the record. But, there is no hard and fast rule that I can find that says you have to have the CDI queries permanent. Good luck!
Tracie