by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.
Specific instances where Yes/No queries are acceptable
In general, queries should not be designed to ask questions that result in a Yes/No response. Like everything in life, there are exceptions.
1. Exception: POA queries when a diagnosis has already been documented.
Was the pressure ulcer POA? Yes/No
2. Substantiating or further specifying “a diagnosis that is already present in the record”
Is this patient’s diabetes insulin dependent? Yes/No
3. Establishing a cause-and-effect relationship between documented conditions such as manifestation/etiology, complications and conditions/diagnostic findings
Is there a cause and effect relationship between the patient hypertension and their heart failure? Yes/No
4. To resolve conflicting practitioner documentation
A consultant states the patient’s BMI is 30 but the dietician states it is 41.7.
Is the dietician’s calculation correct? Yes/No
Anytime you are presenting a physician with a Yes/No type query, always offer an “other” option for uncertain/unclear and to create a space for the physician to leave a comment.
Dealing With Legibility Issues And Challenging Handwriting?
- AHIMA Practice Brief: Managing an Effective Query Process, 2008
- AHIMA Practice Brief: Ensuring Legibility of Patient Records, 2003
- AHIMA Practice Brief: Guidance for Clinical Documentation Improvement Programs, 2010
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