University of Utah Health (Utah Health)—comprised of four hospitals, 10 neighborhood health centers, and 92 specialty clinics in Salt Lake City, UT—embarked on the ambitious project of evaluating the quality and consistency of clinical documentation improvement (CDI) queries to ensure they were written appropriately by CDI staff. Utah Health’s Michelle Knuckles, RHIT, manager of CDI and inpatient coding, and Nancy Treacy, MPH, RHIA, CCS, manager of data integrity, described the undertaking in their Sunday Clinical Coding Meeting session “Queries: To Audit or Not to Audit… That Is the Question!”
The project team focused on CDI queries written by the eight RN inpatient CDI specialists. The queries are created electronically within the electronic health record (EHR) in the form of a progress note and are part of the permanent legal health record. The team determined that the queries needed to be professional, clear, addressed to the correct provider, grammatically correct, warranted for the admission, and similar in look and feel as well as include indicators, treatment, risk factors, and documentation being referenced.
The baseline query writing assessment indicated that many of the queries did not meet all the requirements. A weighted query audit tool (based on CDI industry and facility-specific guidelines), audit process, and a feedback path to the query writers were created. To verify the audit tool, each query was audited by two different auditors. Each month, approximately three audits were done per nurse. The ultimate goal was to have an audit tool with clear definitions and that includes the most critical criteria, so the results are consistent regardless of who performs the audit. Some of the query audit results indicated that queries were leading and unclear. They also found that queries offered responses that were not pertinent to the admission based on the documentation present.
An audit of 240 queries as well as the associated policies and procedures was performed by an external vendor. The data from the internal and external audits along with CDI staff input, was then reviewed and analyzed with the goal of revising the query templates and, ultimately, adjusting and improving the audit tool.
“The initial query audit tool was too complicated… we realized we just needed to get down to basics,” Treacy said. “The result was a query tool 3.0 that included just five criteria.”
An improved audit tool will yield data that is more accurate and provide feedback that is constructive and beneficial to each of the CDI nurses. Improved queries that are clear and consistent will help strengthen the CDI and coding staff relationship with providers, Treacy said, and will result in improved clinical documentation integrity.