Cynthia Prayzner at Southcoast Health System in New Bedford, Mass., offers this sample altered mental status query form which asks physicians to identify the chronicity of the diagnosis providing additional specificity not on the query form but in the medical record's progress note.
This sample query regarding establishing cause and effect relationships between diagnoses was donated by Paul Evans, RHIA, CCS, CCS-P, CCDS, Manager, Regional Clinical Documentation & Coding Integrity, at SutterHealth in San Francisco, Calif.
Attached is the powerpoint presentation "The Art of Communication in CDI and Beyond," by Colleen Stukenberg, MSN, RN, CCDS, CMSRN, Clinical Documentation Management Professional at FHN Memorial Hospital in Freeport, IL.
Attached is the powerpoint presentation "Challenges of the EHR and Electronic Querying," by Joy A. Coletti, BSN, MBA, RN, CCDS, Director, Clinical Documentation Improvement at Memorial Hermann Healthcare System in Houston.
