The Abstractor
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!
Good Work!
Thank you!!!
Doing Great!
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
Email: jamie.thomas@utsouthwestern.edu
Location: CS5.102B
Phone: 214-648-2861