Health Information Management

Tip of the week: Revisit query forms in light of AHIMA final physician query practice brief

HIM Connection, October 21, 2008

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The American Health Information Management Association (AHIMA) on Sept. 29 released its long-awaited guidance on physician queries titled, "Managing an Effective Query Process." The brief, which continues to focus on compliant querying, updates AHIMA’s 2001 version of a similar document titled, "Developing a Physician Query Process."

AHIMA adds in its brief that a query should generally include the following information:

  • Patient name
  • Admission date and/or date of service
  • Health record number
  • Account number
  • Date query initiated
  • Name and contact information of the individual initiating the query
  • Statement of the issue in the form of a question along with clinical indicators specified from the chart (e.g., history and physical states urosepsis, lab reports WBC of 14,400. Emergency department reports fever of 102)

The brief also addresses checklists, yes/no questions, verbal queries, and more. You can read the new practice brief on the AHIMA Web site. To sign up for HCPro’s November 6 audio conference that will address physician queries in light of the new brief, click here.



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