Tip: Incorporate diagnosis criteria into query forms

ACDIS members who frequently use the CDI Talk message board already appreciate the hard work and generosity of Sandy Beatty, RN, BSN, C-CDI, clinical documentation specialist at Columbus (IN) Regional Hospital. She happened to be working on incorporating diagnostic definition criteria into her facility query forms and thought she’d share the information with the group.

 

“My thought is to educate, be compliant, and try to appeal to the MDs’ acceptance by quoting the sources for the definitions from their own professional organizations/societies and the evidence-based guidelines for treatment,” she says.

 

As CDI Talk requests for her to share her forms grew, she decided the best place for the collection of nearly 10 query templates would be the ACDIS Forms & Tools Library on the ACDIS Web site. Forms include clinical diagnosis information from cardiogenic shock to malnutrition, from sepsis to renal failure. The forms include sourced definitions but are intended as a sample only and any diagnostic criteria should meet the approval of your medical staff.

 

Beatty sent the forms to her facility Medical Staff Quality Management Committee for approval. The committee is composed of section chiefs, the chief medical officer/VP medical staff services, the medical director of quality, and other senior hospital leaders.