Q&A: Documenting yes/no query responses
Q: If a provider answers “yes” or “no” to a yes/no query on the actual query template, does the provider also need to document their diagnosis in a note? If the query is part of the permanent medical record, does that answer on the query template suffice and eliminate the need for the provider to document their answer/clarification in a note?
A: The yes/no query is utilized for direct questions in relation to an already documented condition(s) within the medical record. A yes/no query should not be used to obtain a new or undocumented diagnosis or condition. We often use a yes/no query for the following query situations:
- Determining present on admission (POA) status
- Establishing a cause-and-effect relationship between two conditions, or between a complication and the contributing intervention or treatment
- Substantiating a diagnosis that is documented within the medical record (e.g., radiology report, pathology report)
- Resolving conflicting documentation between providers
While it is always best practice and recommended that a provider document directly within the medical record, you should check with your organization in relation to their policy on this. Some organizations do permit queries to be used for the reporting of conditions when considered part of the medical record. You should be able to obtain this information from the health information/medical record department of your organization.
Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at dwilk@hcpro.com.