Health Information Management

Q&A: Michigan ACDIS chapter offers opinions on verbal orders in CDI

CDI Strategies, September 16, 2010

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Q: Our CDI specialists call the physicians when queries have not been answered. Sometimes the physician will give us an answer over the phone. I’m wondering if that’s okay. Can our CDI staff, who are registered nurses, take the verbal response as long as the treating physician signs it?

A: If a clarification request has not been addressed within 24 hours we attempt to talk with the physician face to face. If we aren't able to do that we phone them,” says Tracey Fischer, RN, CDI specialist at Metro Health Hospital, in Wyoming, MI. “The physician should document in the EMR if they feel the clarification is appropriate. We [CDI staff] do not document in any part of the permanent medical record. If a clarification is still not addressed after the meeting or phone call it then goes to our physician champion for follow up regarding the no response.”

“My answer comes from my coder brain,” says Sharin L. Cancilla, RHIT, CDI specialist at Botsford Hospital in Farmington Hills, MI, “which is, ‘if it isn't written in the chart, it didn't happen.’ So, my vote would be that it ultimately has to be documented in the chart. If you can get them to verbally agree with whatever query you have, that's great! But, still get them to document it in the chart.”

“We just had a situation similar and decided not to take verbal physician responses,” says Denyatta Henry, MBA, RN, CCS, manager of CDMP at McLaren Regional Medical Center in Flint, MI. “If the physician refuses to respond by documenting on our permanent query form, which is considered a physician progress note, we will count it as a declined query. If you are completely electronic, you could consider adding it to your problem (dx) list and having the physician electronically sign.
“Since we are not involved in the hands on care and treatment of the patient, it would be unethical to take a ‘verbal order’ and document anything that is related to our query in the medical record,” says Brenda Etefia, MSN, RN, senior manager of clinical documentation at Accretive Health, Inc., in Chicago. “As CDI nurses we are held to the same standards as the coders as well as the ethical standards for nursing.”
“Verbal interactions can be more leading than written queries,” adds Barbara Lockwood, CDI specialist at Hurley Medical Center in Flint, MI. “The bottom line is that the physician is responsible for documentation, not the CDS or the coders.”
Editor’s Note: This question and answer were part of an internal Michigan ACDIS Chapter discussion, reprinted here with the participants’ permission. ACDIS currently has chapters across the country including recently formed networking groups in Hawaii, Wisconsin, South Carolina, Virginia, and Texas. Visit the ACDIS website for a complete listing.

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