lmlund5@hotmail.com
Good morning, I am curious to know if anyone out there is currently tackling the challenges of Ambulatory/Outpatient CDS, addressing missing diagnoses on the Problem List prior to the outpatient MD/patient encounter. What methods are you using to capture all relevant diagnoses with the greatest specificity? Are you adding diagnoses to the Problem List for the MD to edit (MD would either agree with/leave dx on the Problem List or disagree with/remove dx)? It is my understanding that if a CDS adds a diagnosis to the Problem List, then he/she would essentially be asking the MD a yes/no query. The new AHIMA guidelines for achieving a compliant query practice states that we cannot ask a yes/no query to obtain a new diagnosis. Thank you, Lisa
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