by Christopher G. Richards, RHIA, CCS, Senior Associate, Barry Libman, Inc.
How to format your query
All physician queries should be structured in a consistent manner. At a minimum, include:
- Patient name
- Admission and/or discharge date/date of service
- Medical record number/Account number
- Date of the query
- Name/contact information of coder or person raising the issue/concern.
You then formulate and state the issue you need documented.
How to develop the statement of the issue at the heart of the query:
All physician queries should contain elements of the following:
- Must be presented as a question
- Must include factual clinical indicators from the chart and must ask the physician to make a clinical interpretation of those facts
- The query format should not sound presumptive, directing, prodding, probing or as though the clinician is being led to a diagnosis
- AND – must instruct the physician where to document the clarification resulting from the query.
The importance of an organization’s physician query policy and procedures
The hospital needs to have good policies and procedures that it can follow when it comes to the use of physician queries. Organizational policy and procedures should address:
- Consistency of the query format
- Frequency and appropriateness (query fatigue)
- Insuring compliance and addressing non-compliance
- Policy maintenance
More important than anything else – the policy must address whether the physical query form becomes a permanent part of the medical record or whether the physicians are required to clarify the query answer in a progress note or somewhere as an addendum.
Specific Examples of Common Query Scenarios and Four Key Aspects of Documentation
- 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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