Tip: Add physician education elements to your query/clarification forms

April 29, 2010

Many CDI specialists struggle with the problem of educating physicians about documentation requirements. Typical trouble areas include acute kidney failure versus acute renal failure or acute renal injury. While some CDI managers have a chance to educate new physician staff in one-on-one sessions or regularly present at physician education sessions, not all programs enjoy that opportunity.

At Emerson Hospital in Concord, MA, CDI Specialist Patty Spry, RN, snuck in a little physician education for congestive heart failure (CHF) by including important clinical standards on the reverse side of the facility’s standard CHF query form.

“We have had success with getting docs to define CHF that way,” Spry says.

The front, or query portion, of the form addresses the specific physician and the date of the query. It then asks the physician to reference the supporting information on the back of the form to clarify in his/her progress note and discharge summary the nature and acuity of the CHF.

The supporting information defines an acute condition as a first event, acute on chronic as subsequent events, and chronic as a condition maintained by any combination of medications (Emerson’s form lists the medications).

It further outlines guidance for diastolic heart failure as:

Evidence of diastolic dysfunction on echo
Evidence of normal systolic function with an EF>50% during a heart failure event (sometimes called right sided heart failure)
Concentric left ventricular hypertrophy & abnormal diastolic filling

The form provides for the following clinical indicators of systolic heart failure:

Evidence of reduced extent of contraction during systole resulting in systolic dysfunction
EF<40-50% (sometimes called left sided heart failure)
Left ventricular dilation & Low cardiac output

ACDIS members can access the sample query and supporting education in the Forms & Tools Library.

Found in Categories:

Education, Physician Queries