Sample policy: Standard operating procedure offered for query practices

The concept of standard operating procedures (SOP) might easily call to mind assembly lines or retail-related employee handbooks. But CDI programs should establish such basic operating policies to clarify expectations for CDI staff and the healthcare professionals who interact with them.

 

In the latest addition to the ACDIS Forms & Tools Library, Robert S. Hodges, BSN, MSN, RN, clinical documentation improvement specialist at Aleda E. Lutz VAMC in Saginaw, MI, provides a sample query SOP which outlines basic definitions of reportable conditions, query types, and query expectations. Hodges developed it when he arrived at the facility to standardized the informal process previously in place. Based on the AHIMA physician query practice brief, he expects to review and revise the procedure every three years or as warranted by changing practices and official guidance.

 

“The coders are glad it’s there and it gives us a consistent process in the organization for queries,” he says.

 

Hodges also shared two samples of internal CDI newsletters he creates for his facility’s physicians to help educate them on top query items and opportunities for documentation improvement.

 

“The newsletters help address issues identified by coding or billing as areas where improved documentation can be important, or more frequently, where I have been sending a lot of clarification requests on a topic and broader education seems needed.  Overall the newsletters are well received by staff and I frequently get calls or e-mails back requesting a bit more clarification or suggestions for future topics,” says Hodges. 

 

The samples provided discuss sepsis and acute renal failure, items many CDI professionals struggle with. As a reminder, samples on the Forms & Tools Library should be customized to your own facilities, and whenever possible the CDI team should seek input from a variety of CDI stakeholders, including compliance, health information management, and medical staff, and finance, among others, before implementing new policies and procedures.