Query creation using health records
Your organization is in the process of implementing a clinical documentation improvement program. The newly appointed clinical documentation improvement Director has made it clear that she is not interested in having input from the health information management department on the program’s development. However, in your role as health information management Director, someone has made you aware of a clinical documentation improvement policy stating that once a query is answered and the information passed on to the coder, the query form will not be retained since they are still done via paper.
1. Consider how to approach the clinical documentation improvement director with your differing opinion on this policy. Consider compliance with health records contained within the healthcare facility. Consider the electronic health record has the capacity to create and store queries in the appropriate patient health records.
2. Search online for any query retention policy/information to use in approaching the clinical documentation improvement director( Provide the site link)
In your own words, provide information on what this policy states in retaining queries and where they may be stored
3. In at least 300 words, justify your position regarding 1-2 above.
Identify the rationale of your position by addressing the use of the electronic health record as a means for query creation/processes. Back up your reasoning with your research and findings.


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