A recent Q&A featured in 'CDI Strategies' April 16, 2015, caught my eye as it was about the appropriateness of putting certain information in a query. They talked about the rationale behind including mentions of Severity of Illness (SOI) and Risk of Mortality (ROM), as well as support for the level of care for the patient. I agreed with the respondent of the question that it is not necessary to put this type of language in a query, and probably is somewhat a gray area when it comes to the 2013 practice brief on Queries by ACDIS and AHIMA. It is important to remember the goal of the CDI program is to assure that the most accurate, complete and compliant documentation is contained in the medical record. With this goal in mind, the CDI specialist should utilize the 3-legged stool philosophy for presenting queries to the provider. The query should contain:
- The clinical picture
- The clinical treatments, and
- The clinical associated conditions that led to the query presented.
Providers are usually time constrained and so keeping the query concise with the minimal amount of information needed will assist the provider's response. If further education to the provider is needed around the query process and guidelines to which your organization adheres, then this should be done as a separate educational meeting and not within the query templates, from my opinion.