Queries: A Legal Part of the Medical Record - Mercy Medical Center

Queries: A Legal Part of the Medical Record

Posted on: May 24, 2017

Providers were informed in August 2016 that queries were approved by our legal department to be part of the medical record. Answered, signed and dated queries are permanently filed in Meditech as a progress note under “Med Rec Forms.”

When answering a query, please answer to the best of your ability using professional language. Please refrain from analogies or personal comments.

If you need to write an answer, please use the free text box or the “other” line. Please refrain from writing answers in the “unable to determine” box, unless you cannot clinically make that judgement. Please give a brief explanation why you cannot clinically determine.

Example:

Query for type of CHF; Physician: “unable to determine no available echocardiogram.”

If you write an answer agreeing with the query in the unable to determine box, it will be logged that you disagreed with the query request and this will cause inaccurate tracking.

Queries are discoverable; our CDI staff strives to uphold legal compliancy. 

If you have not been set up to use the Chartwise Electronic Query System, please contact: 

Gina Lewis, RN
Senior Documentation Specialist

gina.lewis@cantonmercy.org
330-489-1111, Ext. 5857 

As a facility, Mercy Medical Center would like a uniform process for all providers.

Providers: To start the registration processes please send Gina Lewis the email you frequently use and she will register it with Chartwise. Once you are registered, Gina will contact you to set up a 10-minute meeting time to log you into the system and go over the query process.

 

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