Explanation
One of the factors that an organization should consider when developing a query retention policy and procedure is if the query is considered part of the health record or not. According to the AHIMA/ACDIS query practice brief1, a query is considered part of the health record if it meets any of the following criteria:
It is used to clarify documentation that affects code assignment or other data elements It is used to support clinical validation of a diagnosis or procedure It is used to support medical necessity or quality indicators It is used to communicate clinical information between providers If a query is part of the health record, it should be retained according to the organization's health record retention policy and procedure, which should comply with federal, state, and local laws and regulations. The query retention policy and procedure should also address issues such as:
The format and location of the query (e.g., paper, electronic, hybrid)
The security and confidentiality of the query
The accessibility and availability of the query
The ownership and custodianship of the query
The legal implications and evidentiary value of the query
References:
CDIP Exam Content Outline (https://www.ahima.org/media/1z0x0x1a/cdip-exam-content-outline.pdf) Guidelines for Achieving a Compliant Query Practice-2022 Update1