Q&A: Electronic query formatting

Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?

A: This is going to be contingent on the system your facility uses.

Some EHRs have pretty complex platforms that will allow you to build templates and write a narrative. Here you would write your question, provide all of the appropriate details, and there would be a more formatted, outlined section below where the individual leaving the query can populate the form within that template.

If you have an electronic system that only allows for a message center, for example, it may be worth sitting down as a department and writing an approved-language template.

Let’s say you are using something rudimentary, like a messaging system where you are essentially writing an e-mail within the EHR system. Having those approved and outlined narratives available to all coders and clinical documentation staff will streamline your process and make for a more successful and precise query. Staff still have the freedom to write a narrative and add in case-pertinent details, but they are following compliant language and templates.

Having predetermined templates will simplify your process and decrease the chance of error.

Editor’s note: This Q&A originally appeared in JustCoding. Jonathan M. LaFleur, BSN, RN, CCS, auditor at HRS in Baltimore, Maryland, answered this question in the recent HCPro webinar Acute Kidney Injury: Recognize Clinical Criteria for Proper Documentation, Coding. This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.