Health Information Management

Q&A: Making present-on-admission queries part of the record

CDI Strategies, December 1, 2011

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Q:Should present-on-admission (POA) queries stay in the record and become a part of the permanent medical record?

A:I am a proponent of making all queries a permanent part of the record. I think when they are incorporated as part of the record they provide a logical rationale for how certain diagnoses begin to appear in the record.  For example, let’s say the CDI specialist places a query for specificity and subsequently the physician documents a more specific diagnosis.
 
You will have to raise this topic with management and compliance staff to see what works best in your facility. One facility made the POA query form a permanent part of the record and used only in the following circumstances:
  • A provider already documented the diagnosis at least once  
  • The query only asked if the condition was POA
  • The query did not seek to obtain an initial documentation of a diagnosis
Before making your queries a permanent part of the record you will have to consider:
  • Is the query wording “compliant”?
  • Is it “non-leading”?
  • Will your queries be audited on a routine basis for compliance and how will that be tracked?
  • Do you have detailed written query policies and procedures and if not do you have a plan to develop them?
The AHIMA’s October 2008 guidance "Managing an Effective Query Process" offers additional information on creating query policies and procedures as well as guidance on what is, and what is not, considered a “leading” query. Similarly, AHIMA’s Clinical Documentation Improvement Toolkit (which included input from ACDIS Advisory Board members) offers a number of examples of query policies.
 
While these documents do not address the question of query retention, Recovery Audit Contractors (RAC) have been known to seek queries as part of their medical record reviews. Anecdotally some facilities believe that if they did not keep their queries as a permanent part of the medical record then they would not have to submit them to the RAC. You can read more about this in the July 2010 edition of The CDI Journal.
 
Editor’s Note: Lynne Spryszak, RN, CCDS, CPC-A, AHIMA-Approved ICD-10 CM/PCS Trainer, CDI Education Director for HCPro Inc., in Danvers, MA, answered this question. Contact her at lspryszak@hcpro.com.



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