Guest Post: To lead or not to lead: Forming compliant queries

by Sylvia Hoffman, RN

“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

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.

Asking a physician to clarify the reason for a patient’s low hemoglobin can elicit any where from 20-30 different responses. Won’t abbreviated or less specific queries formed from the fear of compliance risks associated with “leading” a physician cause CDI programs to loose credibility? Physicians think we don’t know what we are talking about when we put vague queries in the chart for them.

The AHIMA practice brief states that the primary purpose of health record documentation is continuity of patient care. There can be no continuity if the communication between the CDI and the physician is weighed down in a quagmire of verbiage red-tape.

Nurses have historically had an ongoing dialogue with physicians. Nurses call to inform a doctor when a transfusion is indicated, when a patient is running a fever, has tachycardia, an elevated white count and may be getting septic. They even call to let a physician know that the intensive care patient is in acute respiratory failure and needs stat intubation. When did talking about a patient’s medical condition become leading?

I always felt like a respected member of the healthcare team, and now, sometimes, I feel reduced to the role of riddle writing pest. Shakespeare was right when he doubted the validity of taking arms against a sea of troubles. Perhaps it is easier to sleep and say “We end.”

Read the AHIMA physician query practice brief “Managing an Effective Query Procces.”

Editor's note: Hoffman, at the time of this article's release, was a CDIS in Tampa Florida. She has been a nurse for more than 20 years and enjoys writing, painting, and travelling.