unanswered physician query

afeighnerafeighner
in CDI Talk Archive
Hi, I need some guidance for document management on physician queries that are answered in the progress notes but not written on the actual query:

When a concurrent written query is posed in the medical record and is not answered on the query sheet, but is answered in the progress notes, should the written copy of the query be retained with the medical record, to show where the prompt for the new information came from ? If the answer is yes, is this unsigned/unanswered query form included when the medical record is requested for release of information?

Thank you!


Amber L. Feighner RN, BSN, CDIS
afeighner@bvhealthsystem.org

Comments

  • vanessa.falkoffvanessa.falkoff
    edited May 2016
    We consider this an answered query and make a note on the query that
    says" answered in progress notes 4/15/13- thank you Dr. Quick!"

    Vanessa Falkoff RN
    Clinical Documentation Coordinator
    University Medical Center
    Las Vegas, NV
    vanessa.falkoff@umcsn.com
    office 702-383-7322
    cell 702-204-0054
  • canipeccanipec
    edited May 2016
    Agree with Vanessa, that's how we handle this as well.


    Carol Canipe RN, BSN, CCDS
    Clinical Performance Improvement
    704-834-4980
    Caromont Health
    Gastonia, NC 28053
  • ddouthitddouthit
    edited May 2016
    We too consider this an answered query. We have a stamp that we stamp query that states:
    "Physician documented in Medical record."
    "Date __________"
    "By_____________"
    Our queries are part of our permanent medical record.

    Dorie Douthit, RHIT,CCS
  • afeighnerafeighner
    edited May 2016
    Thank you all for your responses!

    Amber L. Feighner RN BSN CDIS
    Clinical Documentation Improvement Specialist
    Blanchard Valley Hospital
    1900 South Main Street
    Findlay, Ohio 45840
    419-425-5787
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