Q&A: Pulling queries from patient charts

Q: At my facility, we are to “pull” bad or un-credible queries from patient charts and report the query to our manager. Is there any official guidance on this practice?

A: As a manager, I would never ask my staff to be so confrontational. I would never ask a CDI specialist to pull a query by another coworker. If they found something terribly concerning, it should be reported to the manager and the manager can determine if the query should be pulled.

Queries should be audited on a regular basis—the manager or designee should regularly perform random audits of queries to ensure they are written compliantly and are appropriately assigned (no queries for unwarranted reasons), and to identify missed query opportunities.

Many departments will ask for peer reviews, where each CDI specialist performs a random audit on a coworker and then the information is shared and discussed as a group.

This example, in my opinion, is not related to CDI ethics, but rather management and leadership. Every program should have a method of query audit and review.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Danvers, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.