Questions to Ask Regarding Electronic
x Will the query software interface with the current EHR?
x Are log-in credentials based on role-based access?
x How will physician communication occur (e.g., e-mail,
x Can the physician “override” the communication?
x Does the software allow the physician to sign one que-
ry at a time or all queries with one click?
x Where will the queries attach to the EHR (e.g., progress
notes, dictation, physician orders)?
x Does the query software allow for electronic signa-
tures? Does the electronic signature contain a date and
x What standard reports can be obtained from the sys-
x If multiple query forms are needed, does the system
have the capability to handle multiple forms?
x How are query forms updated or revised?
x Can the system handle both concurrent and retrospec-
on a routine basis. In addition, log-in credentials for the query
system should meet the organization’s policies and procedures
for system access security.
Other issues to consider for implementation include how testing will occur, who is responsible for testing, and who will be
responsible for training on new functionalities.
Query Status and Location
Finally, organizations should clearly define how the query affects the legal health record and the location of the query within
the EHR. Each individual organization must determine if the
query is a part of the legal health record.
Some organizations do not feel that the query directly affects
the care of the patient and the addition of a query does not
change the course of treatment and is therefore not a part of
the legal health record. Other organizations utilize the query to
demonstrate transparency in documentation and clarification,
specifically to third-party auditors, and consider it a part of the
legal health record.
If the query is considered part of the legal health record, then
organizations should determine its place within the record. As
part of the legal health record, the query then becomes a component of the record that is analyzed for completion.
Analysis of the record would include a review of the query for
a physician signature. Organizations must then determine if an
unsigned query is a deficiency for the physician. These deficiencies may or may not be part of the suspension process; however,
the time frame for completing the deficiency should be the same
as other deficiencies. For example, if the organization requires
all deficiencies to be completed within 30 days of discharge, the
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