“I love a form”: The Case for Written Documentation Queries

In this article, “clinicians” refers to all types of healthcare workers; Doctors, nurses, and allied health professionals included.

Verbal documentation queries are favoured by many Clinical Documentation Specialists (CDSs). They give us those invaluable moments of rapport-building with clinicians, providing the opportunity to educate about quality documentation practices and the importance of our work, in addition to allowing us to get documentation that reflects the full clinical truth.

But it’s vital we don’t forget the humble written query. In my time as a CDS, I have seen many CDSs look down on the written query infavour of discussing documentation directly with clinicians. While written queries will never replace the importance of verbal interaction with clinicians, they have their own set ofadvantages especially when working in a private hospital with paper-based records (yes, we still exist!). When done well, written queries are an effective and important part of any good CDS tool kit.

Why written queries work

A time saver.

One of the biggest barriers to CDS work is time-poor clinicians. Clinicians can be hard to pin down and reluctant to be distracted from patient care to discuss documentation. Written queries allow a clinician to respond when it is convenient for them. It also allows CDSs to present the issue and what needs to be clarified in the most concise form possible. It is the most time efficient type of query.

It also saves the CDS time by not having to find the clinician or wait for them to visit the ward. The written query waits in the file on behalf of the CDS, allowing the CDS to review more files or complete tasks.

Catering to preferences

Some clinicians simply prefer written queries; as one clinician said to me “I love a form!”. While CDSs may prefer verbal queries as these give us a chance to connect, educate, and get the most detail we can, our manner of work requires give and take. We should try to cater to the preferences of the clinicians we work with to show that we respect their time and work, and to make our work as unobtrusive and easy for the clinician as we can, and using the preferred query format for a clinician is a fantastic way to do this. In the same way verbal queries help us build rapport through connection, written queries build rapport through respecting a clinician’s preferences.

Clarity

The documentation that a clinician produces after a verbal query is not always what was needed by the CDS; it may not clarify the issue at hand or be optimal for coding. This frustrating scenario can be avoided by the written query through having the clinician respond to the specific question or through tick boxes. For example, instead of having a clinician document “anaemia in the setting of melaena” to a verbal query for the cause of anaemia, we can have them respond to the written query “what is the underlying cause of the anaemia?”. This reduces the risk of needing to re-query and makes written queries especially useful where a specific question is being clarified or piece of detail sought.

Limitations and considerations

I am not advocating we do away with face-to-face interaction. Written queries are great, but they are not a replacement for building rapport and providing education with clinicians in person. It is important that the CDS in any hospital is a known face and not just pieces of paper left in files. The education provided through verbal queries, ad hoc conversations, or formal education remain a vital pillar of the CDS role. Written queries can provide some education, but it cannot provide the robust discussions through which behavioural change is cultivated.

Additionally, documentation queries can be complicated. Between explaining why documentation needs to be a certain way, making sure a query is ethical, explaining why this sort of query makes a difference…sometimes it’s just too much for one piece of paper! There is a limit to the amount of detail and explanation a CDS can include on a written query while keeping it to one page and this is where verbal queries are essential.

How to write a good query

Written queries should ofcourse include patient identifiers, the name and signature of the CDS who has written it, the date, and plenty of space for the clinician to respond. In addition to these practicalities, below is some advice for writing the perfect query.

Ethics

• Queries are all about capturing the clinical truth, so be sure to avoid writing questions in a way that leads the clinician.
  • “Were IV fluids given to treat dehydration?” is leading.
  • “Please clarify what issue(s) were being treated with IV fluids” will capture the same information without leading the clinician.
• When using tick boxes, always include options that allow the clinicians to:
  • Write in an answer you haven’t included (e.g “other; please specify”)
  • Allows them to say they cannot determine the answer (e.g “unable to clinically determine”).
    
    

Clarity

• Ask questions one at a time, making it very clear what piece of documentation you are looking to clarity. Think about how it will be read by the clinician.
  • “Please provide the details of this cancer?” makes it unclear exactly what you are asking for.
  • “Please clarify the morphology of the cancer (if known)?”; “Please clarify the number and location of metastasis (ifknown)?”. These questions make it very clear what details are being sought.
• Use quotes and exerts from the documentation and include where these can be found.
  • On 01/02 “transfuse 1X PRBC” is documented in the progress notes.
    
    

Education

• Include the why: why does this need to be documented differently? Why is the extra detail needed? What impact does this have on patient safety, communication and data integrity?
  • "This information will help to accurately represent the complexity of this patients admission".
    
    

Placement

• For hospitals using handwritten files, place the query in a spot that is easily seen and accessed by the clinician. This could be at the front of the file or in the progress notes where they will next do their documentation.
• Using coloured paper or sticky notes can also help to make your query stand out and be seen by the clinician.
• If you have an electronic record, try to sendt he query in a way that makes it easiest for the clinician to reply. For example, if it is sent as an email can they reply directly to your email? If you can send it through the electronic record system, can they reply directly to your message?

Conclusion

While verbal queries are highly valued by CDSs, it’s important that we don’t forget about the written query. When done well, they offer a time-efficient way for a CDSs to get the information they need, while showing respect for a clinician’s time and preferences. Verbal queries should not be seen as superior to written queries; they should be seen as different but equal ways to achieve clarity, detail, and accuracy in the clinical record.