Health Information Management

Survey: Are queries a permanent part of the medical record?

CDI Strategies, October 15, 2009

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An HCPro Inc. poll posted this week asked healthcare compliance professionals if their CDI programs keep queries permanently in the medical record. A 5% margin separated query keepers (45%) from non-keepers (50%), as of this writing. A similar ACDIS Weekly Poll found 77% of respondents said they remove the query from the record after the physician clarifies his or her documentation in the medical record and 20% said they keep queries as a permanent part of the medical record.

In a more detailed survey of ACDIS members regarding physician query best practices in April only 28% of respondents said they kept queries as a permanent part of the medical record.

“I’m actually surprised by how many [people] do not keep the queries in the chart,” Gloryanne Bryant, BA, RHIA, RHIT, CCS, CCDS, regional managing director HIM (Revenue Cycle N. California) for Kaiser Permanente in Oakland, CA, said in the survey analysis White Paper Use CDI Best Practices to Query Physicians.

There could be a potential compliance risk if an auditor sees a sudden change in diagnosis in the medical record without additional query information. This lack of documentation in turn could raise questions about leading queries. Some CDI programs use a central tracking database and maintain query forms within the CDI department to satisfy such documentation needs.

However you handle queries, make sure your CDI policies and procedures are clear. Define what will be kept and for how long. Also, describe how you will connect queries to medical records in the event Recovery Audit Contractors (RAC) seek additional clarification.

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