To Query or Not to Query?

As I read this blog about “when to query”, it reminded me that there is no time like now when it comes to accurate, complete and compliant queries. With the evolving Electronic Health Record (EHR) it has become more important to query as soon as possible in order to get the documentation complete and accurate. We have all seen the “cut & paste” phenomena or at least the “carry forward” functionality utilized as a time saver. The most important aspect of CDI work is the education of providers around the importance of accurate, complete and “able to be captured with ICD-9 (soon to be ICD-10) codes” documentation. Much of our credibility is based off of the ability to identify improvements in documentation quickly and accurately. We must remind the providers of the importance of the documentation to both the patient care (which is forefront) but to the accurate reporting of the patients LOS requirements, SOI/ROM, and the utilization of resources. It is the relationship with the providers that is the key to successfully completing the important work of a CDI.

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