Q&A: Querying based on unsigned notes

Q: Can we send a query on an unsigned provider note, or should we wait for the provider to be entirely done and have the note signed?

Our goal is to ensure all the valid diagnoses are documented and we try to have all queries answered before discharge, but sometimes providers do go back and amend their documentation before signing the note, which is their right.

A: According to the ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice, the definition of a query is: “…a communication tool or process used to clarify documentation in the health record for documentation integrity and accuracy of diagnosis/procedure/service code(s) assignment for an individual encounter in any healthcare setting. A query may be developed by a healthcare professional or through a computer autogenerated query process.”

The guidelines also state how to query: “When specific information is pulled from the health record to support the query, quotations may be used to identify direct sourcing of clinical information with identification of where the information was pulled.”

When you examine the purpose of the query, it would require you utilize clinical indicators from the established health record. An unfinished note, although sitting within the EHR, is not considered the established nor completed health record until signed and dated by a provider. It would be unwarranted to query based on that information.

I would also advise against this practice from a provider burden and potential erosion of trust and engagement standpoint. If you are querying them based on information that they have not finalized, it would be premature on the part of the CDI team and cause them undue burden, and most likely frustration.

Editor’s note: Deanne Wilk, MPS, BSN, RN, CCDS, CCDS-O, CDIP, CCS, CDI education director at ACDIS/HCPro, answered this question. Contact her at deanne.wilk@hcpro.com.