Physician Query: Step Toward Accurate Reporting - Essay Sample

Introduction

The physician query is a significant step towards the right direction to obtain accuracy and integrity to report particular information. The use of a query is to initiate communication from physicians for clarification or to get additional information. Initiating queries in writing allows the use of a standard form to represent the form of clinical information that is being requested. For a physician, queries are appropriate for documentation of the patient's record to offer clarity, completeness or consistency on the information that is offered. The following paper will perform an audit on the reasons for physician queries and how to reduce the number.

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The most common reasons for physician queries include the need to have clarified information to ensure the diagnosis and procedures listed are clear. Therefore, a clear query ensures that the documentation is complete and accurate, which is significant to tell the history of the patient that will assist to improve care. Another reason for the physician query is to ensure completeness of the patient records and ensure they correlate with the diagnostic tests performed to the patient. Also, a physician query is enquired to enquire about information that may be conflicting or it is not substantiated. Therefore, this will allow for the correctness of the clinical reports especially those that require certain documentation. Physician queries will allow for reviewing the patient's medical records to identify any instances of incomplete documentation of diagnoses. Therefore, the process can offer an approach to improve the documentation of information obtained from patients.

The following report will offer an approach that can be used to reduce the number of queries. The most common type of queries that have been identified are insufficient documentation, CKD staging, hear failure, no documentation, and diabetes. For the given types of queries, they have been enquired for over five instances, which highlights there might be an issue hindering physicians to be efficient and effective. The appropriate moment to query is when an individual is confused about whether the documentation is missing a major fact, when the document appears to have information that is conflicting or ambiguous or when additional details are required.

The use of query templates is of extra importance to ensure physician query is reduced and to ensure a response is given on a particular issue. The templates require to be clinically and succinctly oriented, by ensuring they are not loaded with extraneous information or details (Butler, 2016). Also, physicians should strive to ensure clinical ambiguity in the record is eliminated to ensure that the documented clinical diagnoses are proper. It is evident that most physicians do not prefer queries, communicating the need for a reduced query is the first appropriate step. Thus, a data-based decision will offer the appropriate approach to track query by identifying the most reason for queries, which has been highlighted to be the need for clarification on particular information. Through query tracking, it will assist in designing a program to address the issues. Also, there is a need for physicians to ensure that the presented documentation is clear and accurate. Another approach is to ensure clear charting, to ensure good care offered by the physician does not look bad. Therefore, it is the role of the physicians to ensure that they follow a documentation process that is accurate and clear to reduces the instance of querying.

References

Butler, M. (2016). Querying through the Chaos. How to get docs'attention amidst the digital healthcare haze. Journal of AHIMA, 87(7), 20-25.