February 27, 2015 | | Comments 0
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Book Excerpt: Open-ended queries

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The Physician Queries Handbook

The following is one example of a possible open-ended query:

“Dear Dr. Phil,

The patient’s sodium (Na) was 129, the progress notes indicate low serum sodium level, ‘¯Na.’ An order was written to place the patient on .9NS. Please clarify the associated diagnosis being treated.”

In this scenario, the physician is highly likely to respond and document “hyponatremia.”

The 2013 ACDIS/AHIMA query practice brief describes an obtruded patient with a history of vomiting treated for pneumonia. The open-ended query asks the type/etiology of the pneumonia, which, in that example, most likely result in a response of “aspiration pneumonia.”

Sometimes an open-ended pneumonia query can be problematic, however. For example,

“Dear Dr. Oz,

The patient’s progress note indicates he is being treated for pneumonia with vancomycin. Please clarify the type of pneumonia being treated.”

Although the wording of this query does a great job of not leading, it may not result in the most clinically appropriate answer (methicillin-resistant Staphylococcus aureus pneumonia). In many cases, the physician will respond “bacterial pneumonia,” which will still lack the specificity needed for coding purposes. Other physicians may respond “complex” or severe pneumonia.

In such situations, the CDI specialist would have to use a second query in an attempt to further clarify the issue. The use of open-ended queries works best when the potential answers are limited, involve commonly used terminology, and when physicians essentially understand the type of documentation required.

 Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

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Katherine Rushlau About the Author: Katherine "Katy" Rushlau is the CDI Editor for ACDIS at HCPro.

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