Documentation Inconsistencies - Mercy Medical Center

Documentation Inconsistencies

Posted on: March 13, 2018

Physicians frequently ask CDI staff, “Why am I being queried?” Querying a physician is a vital part of the documentation process to ensure complete and accurate health record documentation.

When to Query

  • Lack of consistent documentation of the diagnosis through the progress notes and discharge summary.
  • Inconsistencies or conflicts between physician documentation.
  • Symptoms not linked to a cause or diagnosis.
  • Uncertainty if a diagnosis was present on admission or not.

Physician Query Examples

  1. A patient was admitted with infiltrates, started on antibiotics, and the CXR impression indicates “suspected pneumonia.” The attending documents pneumonia on the H&P; however, the diagnosis is not carried throughout the progress notes and discharge summary. This scenario requires a query to find out if the condition is ruled in or ruled out or still suspected at time of discharge.
  2. The attending physician documents bronchitis and the pulmonary consultant documents bilateral pneumonia. A query is required to clarify if one or both conditions are ruled in, ruled out or suspected.
  3. The patient comes in with supratherapeutic INR and GI bleed with a history of colon cancer. The patient is prescribed Plavix; treatment is rendered to reverse the INR; however, there is no link as to what caused the GI bleed. A query is generated to find out if the Plavix contributed to the elevated INR/GI bleeding or if the GI bleeding resulted from another cause

5 Tips to Improve Documentation

  1. Indicate when a condition is ruled out or resolved.
  2. Continue to review written paper progress notes until Mercy has a full EMR.
  3. Consistently document any possible, probable or suspected diagnoses through the discharge summary.
  4. Acknowledge your consultants diagnosis. (acute respiratory failure; Defer to pulmonary)
  5. Link symptoms to a condition/dx. (Syncope likely due to PFO)

Chartwise Registration

Dr. David Gormsen and Dr. Amy Indorf would like all physicians to register for the Electronic Query Process in Chartwise as soon as possible. Please contact Gina Lewis, senior CDI, R.N., at ext. 5857 or by email at gina.lewis@cantonmercy.org. Registration and set up takes less than 10 minutes.

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