All Entries Tagged With: "electronic health record"
Does your hospital use the Epic software system? Let’s hear about it
Hi ACDIS members, I’ve had a few questions recently regarding the Epic software system. It was a subject of a member’s question on the most recent quarterly conference call, and I’ve since received a few additional e-mails from facilities that are going to Epic, or plan to do so, and are looking for help from experienced Epic users who have been using the system to leave electronic queries and interface with physicians.
If you would like to share your e-mail address, please feel free to leave it right here by leaving a comment on this post, or you can e-mail me directly at bmurphy@cdiassociation.com.
With more and more facilities going electronic, it would be great to see members sharing best practices, implementation strategies, and other ways of helping one another out with this important transition.
Take care,
Brian
To lead or not to lead: Forming compliant queries
“Whether tis nobler in the mind to suffer
the sling of outrageous fortune,
or to take arms against a sea of troubles,
and by opposing, end them.”
~Hamlet, Act III, Scene I
Shakespear as CDI? Hummm. . .
I truly think that Shakespeare was a frustrated CDI nurse.
I was not fortunate enough to attend the annual ACDIS convention in Las Vegas, but my colleagues let me read through their books. The AHIMA practice brief baffled me when it was introduced in 2008. Has anyone read this carefully? There is an interesting quote from a CMS memorandum issued on October 11, 2001:
“CMS Position is that a query form should not be leading, and it should not introduce new information not otherwise contained in the medical record.”
If a physician documents that a patient has hemoglobin of 5, how can anyone query for anemia if use of the word anemia is prohibited? Furthermore, query forms should not have the name of the condition, diagnosis, or procedure unless such was already listed in the medical record.
Any nurse who works in a hospital intensive care unit has seen the vent setting carefully listed on the record with no mention of the patient being intubated or why. How can a CDI clarify acute respiratory failure and the intubation procedure without mention of the vent, the endotracheal tube or the possible causative diagnosis?
I can understand phrasing the query in a question format (after all I grew up watching Jeopardy): “What is the underlying diagnosis?” I can also understand the rationale for not phrasing the question in a “Yes” or “No” manner. I would not want a physician to say “yes” and then not document anything on the progress note. This is self explanatory. What I have a hard time understanding is what appears to be the systematic torture of physicians who are exposed to ambiguous clarification forms.
AHIMA to start CDI work group
Back in March, AHIMA sent out the call for volunteers to help establish a new work group on clinical documentation improvement. The initiative comes as part of the association’s e-HIM effort and aims to determine industry needs and CDI best practices, according to a release.
“We were overwhelmed with the number of people who wanted to volunteer,” says Kathy DeVault, RHIA, CCS, manager of professional practice resources at AHIMA in Chicago.
ACDIS Advisory Board members are among the list of volunteers. DeVault planned to notify participants and begin a series of weekly, work-group calls in early April but the influx of interest pushed the start date back slightly.
Ten reasons to adopt an electronic query process
Editor’s note: This article first appeared in CDI Strategies, a free weekly e-newsletter.
Many clinical documentation improvement programs remain true to the paper query. Who could envision the death day of the “purple sheet” or “pink sheet,” as some facilities call their query form? But with the federal government promising an intense infusion of funds for health information technology, that day could be on its way.
Need more convincing to consider using an electronic query in your CDI program? Barbara Hinkle-Azzara, RHIA, chief product strategist for Meta Health Technology, a HIM software developer based in New York, outlined her top 10 incentives to move ahead with an electronic query format.