Critical Care Documentation Failures and How to Curb Them This article discusses the discrepancies possible in critical care documentation and ways to curb them.
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Critical care refers to the delivery of medical care for a critically ill or critically injured patient directly by a physician. A critical illness impairs one or more vital organ system to cause an imminent or life-threatening deterioration in the condition of the patient and it requires high complexity medical decision-making to assess, manipulate and support vital organ system function to treat vital organ failure. Complete and accurate documentation that provides substantive information can enhance the quality of care and patient outcome. Let’s take a look into critical care documentation failures and how critical care transcription is still significant.
Your documentation should match the complexity of medical decision making with critical care. The following discrepancies can make your documentation ineffective and adversely affect the quality of your services and reimbursement.
Failing to Document Level of Care – It is required to determine the level of critical care services offered in keeping up with the provider goals and regional needs for the service. Certain levels of care require continuous availability of sophisticated equipment, specialized nurses, and physicians with critical care training, while certain other levels of care require transfer of critically ill patients to critical care centers. Your documentation must support the precise level of care.
Invalid Signatures – The critical care services provided or ordered must be authenticated by the ordering practitioner. If the signature of the practitioner is illegible, it means your services have no authentication. Invalid signatures are most noted in electronic medical records.
No Medical Necessity – If your documentation fails to support the medical necessity of the services rendered, the insurance company will reject your medical claims for the critical care services provided.
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Missing or Insufficient Documentation – Incomplete documentation with missing or insufficient information can adversely affect the quality of care. For example, the omission of infusion diluents from the medication administration record can drastically affect the infusion of IV medication and lead to adverse patient events.
Inadvertent Errors – While documenting the number of cases in a busy emergency care setting, there is a greater chance for inadvertent errors. Such errors can have a huge impact on the quality of care. For example, unit misinterpretations such as ‘mg’ for ‘mcg’ in medication dose can cause serious adverse effects in patients.
Improper Critical Care Time – Critical care services are time-based services. Failing to document the total amount of critical care time for each date of service can lead to claim denials.
When it comes to critical care documentation, you should always correctly document the critical diagnosis and what you did. You must also accurately document the total critical care time involved and it must be a minimum of 30 minutes, exclusive of separately reportable procedure time. The documentation must also support the amount of critical care time aggregated and include a description of:
All interval assessments of the patient’s condition by physicians
Any impairment of organ systems based on the symptoms, signs and diagnostic data
Rationale and timing of interventions
Patient’s response to treatment
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EMR Transcription to Curb Documentation Failures Though electronic medical records (EMRs) support efficient documentation with easy access to data, there is a tendency for practitioners to copy-paste data from previous records to save time. When physicians need to cover more number of cases, frequent copy-pasting occurs and physicians may not check what content they are copying, and into which record they are pasting it. This will lead to documentation errors and inconsistencies. In the case of critical care that demands quick delivery of services, we can see the same practice due to time limitation and this leads to a bunch of errors and inconsistencies. A combined approach of EMR and critical care transcription thus becomes relevant in this scenario.
In this approach, physician recordings are transcribed by experienced transcriptionists and the data thus obtained is checked thoroughly for any errors or inconsistencies by proofreaders and editors. After that, those details are entered into the corresponding EMR fields through discrete reportable transcription (DRT) technology. In this way, you can ensure your critical care documentation is accurate, complete and consistent. Valuable support from medical transcription companies experienced in this field can help you save a lot of time as well.
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800-670-2809