The Abstractor

Volume 3, Issue 6 --- May 9th, 2016

Bi-Weekly Focus: Short Stay Documentation

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Quick Visits: Documentation for hospital day surgeries or overnight encounters.

When a patient has a quick day surgery or overnight stay, typically there tends to be less documentation in the patient's EMR, which makes it difficult to abstract.

The following are just a few friendly reminders for documentation on these types of visits:

  1. What is the patient's Baseline Rankin Score or enough info so that I can score it.
  2. What is their dominant hand? I have noticed with these quick visits, this gets left out. When I cannot find this in the H&P or a clinic note, I look in the therapy notes. Quick stays do not have therapy; therefore, it gets forgotten.
  3. At discharge, are they back to baseline with ADLs (not just neuro).
  4. In some cases, there is not a requirement for a discharge summary due to the number of hours a patient was here. In those cases, please provide information in the progress note or in the procedure note or in the H&P. Otherwise, there will be limited information regarding that visit for me to abstract.

Remember: quick, overnight visits or day visits still require good documentation. The H&P, procedure notes, progress notes and clinic are critical. Please give me all you've got!!!

There are many things going on in the NSY Dept!

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What to see something in the next Abstractor?

Remember if you would like anything to be included in the Abstractor, please just let me know! I will make sure it has a voice!

Jamie Thomas

Neurosurgery Registrar/Abstractor

Performance Improvement Registry Specialist

UT Southwestern Medical Center

Zale Lipshy University Hospital

5151 Harry Hines Blvd

Dallas, TX 75390

Main: 214-645-5555

Cell: 214-620-1277