Q&A: Query author
Q: Our query process currently creates a physician progress note when a query is answered which becomes part of the permanent medical record. We do keep the original query as well, which clearly identifies the query author and it is discoverable, but not as part of the medical record. We included this information under the assumption that it was required for a compliant query. As I was reviewing the “Guidelines for achieving a compliant query practice” brief, however, I couldn’t find anything that says the query author must be included on the version that becomes a part of the permanent record.
In order for a query to be compliant, does the query author need to be identified on the query that becomes part of the permanent medical record, or is it sufficient that this information be discoverable if needed? Is our current process sufficient to meet compliant query practice without also including this information in the progress note response?
A: I have some good news for your CDI specialists who are concerned about their information being on the query in the official medical record: it isn’t required for a compliant query. You are correct that there is nothing mentioned in “Guidelines for achieving a compliant query practice” brief (2019 update) or any previous practice brief. I think this practice originated many years ago when we were all still working in the hospital, and on many different floors without a place to really call our own. Back then, not many people knew who we were or what we did. I remember working out of the HIM department, where we spent very little time at our desk. The phone number we gave out at the time was the main department number, which was a disaster. If the physician did call, they got someone on the phone who had no idea where I was or who I was.
For these reasons, many believed we needed to provide the physician our phone number or e-mail address so, if they had a question about the query, they could get a hold of us right away. In those days, if they didn’t reach us, the query would go unanswered.
Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at email@example.com. For information regarding CDI Boot Camps, click here.