Q&A: Carrying provider documentation to discharge

CDI Strategies - Volume 19, Issue 5

Q: Our physicians are answering our CDI queries and agreeing to the proposed diagnoses but not carrying their documentation forward into their subsequent notes and discharge summary. If your health system has found a solution to help providers carry the query response forward into their subsequent documentation, how were you able to accomplish this? What are your thoughts on a proposed solution to automate query response to populate the active problem list for the physicians?  

Response #1: At our facilities, we direct the provider to answer the query by adding or amending a note in the record. If the provider only responded to the query message, we would not “count” that as a response. We have had many vendors suggest that the provider’s response “stands alone” with the query, with the purpose of obtaining greater efficiency from the provider’s perspective. We did not adopt this approach because our goal was consistency in the record.

Our queries are delivered through our EHR messaging system with instructions to respond in the notes (as opposed to the entire query separately entered in the EHR). This has promoted consistency in the record, as tomorrow’s note is usually a modification of today’s note.

Response #2: To your question about the problem list, it continues to be a problem in our organization due to inconsistent updating, particularly around removing diagnoses that are resolved or ruled out. The problem list in the EHR is from a variety of different sources and settings. If your problem lists are well maintained, then the idea of populating the problem list from the query responses would make perfect sense.

Editor’s note: This question was answered by members of the ACDIS CDI Leadership Council. For the purposes of this article, all Council member answers have been deidentified.

Found in Categories: 
Ask ACDIS, Physician Queries