This is a classic documentation opportunity to clarify “volume/fluid overload,” says Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA. “If the physician hasn’t documented acute CHF, I would hesitate to ask for this condition based on this mild BNP elevation...Read More »
Few managers have the luxury of hiring staff with concurrent record review experience. Thus, once you hire new staff, you need to determine how to train them. Even if the new hire is an experienced nurse who understands core measures, “you can’t just throw him or her a problem list and set them...Read More »
Q: A 79-year-old male nursing home patient presents with lethargy, confusion, and fever after failing an outpatient course of Bactrim for a suspected urinary tract infection (UTI). His white blood count is 22,000, segs 85, bands 10, and blood cultures are negative. He has a temperature...Read More »
Even experienced and consistently accurate acute care hospital coders may not be familiar with pediatric diseases. Age is not a factor for some conditions (e.g., appendicitis). Others are age-specific or have age-specific diagnosis, healing, and treatment...Read More »
No industry or profession is immune to the budget crunch. Unfortunately, many departments fall into a routine, neglect to assess costs, and fail to look for innovative ways to save money. To address the mounting stresses on its budget, Tufts Medical Center in Boston turned to CNG-ONLINE,
If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you! In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical...Read More »
Q: Do you recommend carving out time for outpatient [documentation] review, or dedicating someone to this role?
A: We actually carve out time for outpatient review. We started with two initiatives in our ED. One was injections/infusions and documentation...Read More »
