• E-mail
• Print
• RSS

Tip: Cut to the chase for effective queries

CDI Strategies, November 1, 2007

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

Clinical documentation improvement specialists should reduce the amount of information they include in physician queries and get right to the point, says Robert S. Gold, MD, CEO and co-founder of DCBA, Inc. in Atlanta. "If you leave a three-page diatribe for a physician to read, and the last line is the question, the physician will throw it out," Gold says. "It doesn't work."

The best strategy for developing an effective query process is coupling brief, informative sessions for physicians during their allotted physician meetings, and then writing concise queries based on these sessions, Gold says.

For example, provide education to physicians that the International Classification of Diseases has a certain code for respiratory insufficiency, and a different code for a patient with acute respiratory failure. Instruct physicians that "acute respiratory failure" carries with it a corresponding 30% risk of mortality, and provide a definition of acute respiratory failure from an authoritative source, such as Cecil's Textbook of Medicine. "Let them know that the term 'respiratory insufficiency' is subjective, and that it has no associated severity of illness or risk of mortality component," Gold says.

If you provide this information beforehand, and two days later the clinical documentation specialist leaves a query that states:

You mentioned respiratory acidosis, and the patient has a PH of 7.16 and a PC02 of 105. With your clinical description of severe respiratory distress, does this meet your criteria for acute respiratory failure? If so, could you please document it in the chart?

The physician will instantly add that diagnosis to the chart, Gold says. "[The physician] heard it, now they're seeing it, and after two or three times the physician will automatically use it in his charts--it's now part of [his or her] routine."

Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!

• E-mail to a Colleague
• Print
• RSS
• Archive