The ABSTRACTOR
January 25, 2016 -- Volume 3, Issue 1
Bi-Weeekly Focus: REMINDERS
TOP 3 Doucmentation REMINDERS:
1. Aneurysm Measurements
2. Details at Discharge
3. Temp Occlusion Time
Aneurysm Measurements
Aneurysm measurements are important for the databases. We need the 3 measurements along with a neck size for each AN you find.
Discharge Notes
Details at Discharge are critical for scoring the Discharge Rankin. Questions: Is the patient walking without assistance? Can the patient return to normal activities, when? Is the patient independent with all ADLs?
Temp. Occlusion Time
Temporary Occlusion Time is not often documented. Please include the amount of minutes/seconds the artery was temporary occluded if you use temp. occlusion.
We are only as good as the documentation that is in the Electronic Medical Record!