Volume 3, Issue 6 --- May 9th, 2016
Bi-Weekly Focus: Short Stay Documentation
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:
- What is the patient's Baseline Rankin Score or enough info so that I can score it.
- 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.
- At discharge, are they back to baseline with ADLs (not just neuro).
- 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!
I have noticed your progress notes and H&P information. You are doing a nice job of collecting very detailed information! Please keep it up & keep it detailed!
I have noticed your progress notes and H&P information as well! You are really showing me that you can document clearly! Please keep it up & keep it detailed!