Here are three important changes from our Clinical Documentation Improvement Team to improve your documentation:
PAs can get queries: The CDI team is now able to query physician assistants as well as nurse practitioners and physicians. Before, PAs weren’t queried because they worked under physicians. Since notes have to be co-signed by the supervising physician, it is prudent to query the PA. With some groups, PAs are the rounding providers. For example TRACS and cardiothoracic surgery post op and recently oncology and occasionally gastroenterology PAs are the rounding providers.
You’ll get emails for outstanding queries: The second change is that providers will again be receiving emails for outstanding queries after discharge. If there is an outstanding query you will receive a weekly reminder for three weeks in a row. If not answered, it will be forwarded to the suspension process.
Query responses documented in notes: Any query response needs to be documented in the progress notes. Some physicians just write “done” or “answered in progress note” in the query response itself, then document the answer in the progress notes. Two reasons for this change: 1) It makes the diagnosis visible to other providers. (A response just answered in the query can only be seen by the answering provider), and 2) then hopefully the diagnosis will be carried through in progress notes to discharge. If it is answered only in a query response and not in the chart, a query may need to be sent to another provider as the diagnosis from your query response would not be included in their DC summary.
The goal is to ensure documentation is as accurate and complete as possible. This will represent the true picture of the patient’s acuity.
Questions? Feel free to contact any member on the CDI team. You will find our phone number and email below every query we send. E-mail: karen.gray@salemhealth.org or 503-507-9575.