Use Queries to Prompt Complete Documentation
Queries (also know as clinical clarifications, documentation alerts, or documentation clarifications, among other names) are an essential component of any clinical documentation improvement (CDI) program. A query is a communication and education tool that prompts physicians to provide detail about under-reported conditions found in the medical record.
Queries may address several documentation areas, such as:
- To specify the severity of a condition
- To clarify the underlying cause of a presented symptom
- To substantiate present-on-admission issue
- To identify a potentially preventable complication
As an example, if pneumonia is the primary diagnosis, but the type of pneumonia is not noted, the query may ask the provider to further describe the etiology of the condition, and may even provide options such as “viral,” “bacterial,” “community acquired,” “hospital acquired,” etc.
Warning: Be careful not to design “leading” queries, which may prompt providers to select an unsupported diagnosis, and could lead to upcoding. For example, you may ask a provider to give additional detail about a diagnosis, such as in the pneumonia example cited, but should not attempt to steer the provider’s answer by asking, “Was the pneumonia due to virus?”
The documentation resulting from a query can improve the capture of co-morbidity/complication (CC) and major co-morbidity/complications (MCCs), which optimizes facility reimbursement. By contrast, nonspecific documentation leads to nonspecific coding, and the severity of illness, mortality rate, and intensity of service are not captured. Patient care, data integrity, compliance, and reimbursement suffer.
The physician may answer a query verbally, or in writing in the history or physical, a progress note, or the query form. Providers may complete the queries either concurrently (at the time of the provider/patient encounter) or retrospectively.
Developing clinical indicators to determine when the clinical picture suggests a particular diagnosis ensures that queries will be clear, concise, and timely. These clinical guidelines are written in the query template for each condition, and are updated appropriately.
Several organizations offer example templates, or facilities may create their own guidelines based on medical literature. To learn more, type “CDI queries” into your favorite search engine, and browse the results.