demonstrate your understanding of how to utilize the princip
demonstrate your understanding of how to utilize the principles of… demonstrate your understanding of how to utilize the principles of developing routine messages in writing physician queries. Defend how each step in the writing process will be helpful in composing effective queries. Health information management professionals must establish and maintain effective query processes to produce accurate coded data and ensure data integrity. “A query is defined as aposed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record. Documentation can be greatly improved by a properly functioning query process. reference,Health information management professionals must establish and maintain effective query processes to produce accurate coded data and ensure data integrity. “A query is defined as aposed to a provider to obtain additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes in the patient’s health record. Documentation can be greatly improved by a properly functioning query process (Managing an Effective Query Process, 2008)”. “The Query Format It is recommended that the healthcare entity’s policy address the query format. A query generally includes the following information: ? Patient name ? Admission date and/or date of service ? Health record number ? Account number ? Date query initiated ? Name and contact information of the individual initiating the query ? Statement of the issue in the form of aalong with clinical indicators specified from the chart (e.g., history and physical states urosepsis, lab reports WBC of 14,400. Emergency department report fever of 102) It is not advisable to record queries on handwritten sticky notes, scratch paper, or other notes that can be removed and discarded. The preferred formats for capturing the query include facility-approved query form, facsimile transmission, electronic communication on secure e-mail, or secure IT messaging system. Verbal queries have become more common as a component of the concurrent query process. The desired result of a verbal query is documentation by the provider that supports the coding of a condition, diagnosis, or procedure. Therefore entities should develop specific policies to clearly address this practice and avoid potential compliance risks.It is recommended that queries be written with precise language, identifying clinical indications from the health record and asking the provider to make a clinical interpretation of these facts based on his or her professional judgment of the case. Queries that appear to lead the provider to document a particular response could result in allegations of inappropriate upcoding. The query format should not sound presumptive, directing, prodding, probing, or as though the provider is being led to make an assumption (Managing an Effective Query Process, 2008)”. Health Science Science Nursing HIT 1600
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