MEDITECH 6.1 Upgrade Provider Alert: Responding to Clinical Documentation Improvement Queries in the EMR

RESPONDING to Electronic Query (NEW PROCESS in MEDITECH 6.1) Electronic Queries will show up in your sign queue (similar to MEDITECH 6.0) Select the document, then click the “View and Save” button at bottom of screen You will be informed the report is missing information required for signature, click the “Close” button Click the “Edit Document” at bottom of screen

To view/read the clinical information and the Electronic Query that has been entered, click the drop down arrow in the “Clinical Clarification Query” field. The field displays who the CDI information was entered by. Once you have read the query click the “OK” button at bottom of screen The Provider can NOT edit any of the information provided by the CDI/Coding Staff Select the appropriate diagnosis from the “Problem List”

In your best professional judgement, the diagnosis selected must be to the highest level of acuity/severity/specificity as clinically appropriate

Complete the “Assessment and Plan” section for the diagnosis added You must “Attest” to Updating the Problem List (in response to the Electronic Query), click “Agree” (if you choose a response other than “Agree” you must provide additional comments)

If the Electronic Query is to obtain clarification that does not require the selection of a diagnosis from the Problem List, you must manually type in your response in the green “Query” field next to the line that reads “PHYSICIAN RESPONSE” (as opposed to selecting a diagnosis from the Problem List) For example: the Debridement Query requires clarification for excisional debridement vs non-excisional debridement (the response must be manually entered by the MD) As a reminder please document your response under “Physician Response” and in the PROGRESS NOTES/DISCHARGE SUMMARY

Click “View and Save” button at bottom of screen Click “Save” button at bottom of screen Once you have completed all requirements for the query, click on “Sign” button at bottom of screen You will get alert you have 1 report selected for signature, click on the “Sign” button Enter your “PIN” then the “OK” button