Health Information Management

Q&A: Keep query retention policies consistent

CDI Strategies, August 18, 2011

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Q: Should queries from different departments be treated and stored differently? Should they be placed in a different location or anything along those lines?

A:“Honestly, they should be treated the same way because regardless of the department which originates the query it still is eliciting information to clarify in the record,” says Cheryl Ericson, MS, RN, manager of Clinical Documentation Integrity at Medical University of South Carolina (MUSC) in Charleston. Ericson, a member of the ACDIS Advisory Board, also participated in the AHIMA CDI Work Group which developed guidance governing physician query best practices.
“Now, internally perhaps if you wanted to track which department submitted the query (e.g., CDI or HIM) to see if one area has a better response rate you might include that information in your facility data collection. However if your facility decided to keep queries as a part of the medical record then anyone who submits a query should handle it the same way regardless of which department they report to,” Ericson says.
Conversely, policies and procedures which govern physician query practice should be consistent across the facility. “If you mean, for example, that perhaps CDI staff keeps queries separately as part of the business record and HIM/coding staff keep queries as part of the medical record then I would not recommend that. You would not want to have two separate policies governing query retention,” she says.
“Some people recommend asking queries differently depending on which department is submitting them to the physician,” says Andrew Rothschild, MD, MS, MPH, FAAP, CCDS, director at FTI Consulting in Atlanta. I really think that the concepts should be the same and the approach should be the same regardless of which staff member asks the question. Everything should be consistent.”
Editor’s Note: Ericson and Rothschild answered this question during the audio conference “Physician Queries: Apply Industry Guidance to Improve Procedures and Data Tracking” earlier this year.

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