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There is a significant amount of research that demonstrates ED crowding due to boarding is responsible for poor outcomes, says Tom Scaletta, MD, president of Emergency Excellence, a Chicago-based organization that improves patient care and efficiency in the ED while controlling costs. He also is medical director of a high-volume community hospital in a Chicago suburb.
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If your documentation assurance program focuses on reimbursement alone, you're not going far enough. With pay-for-performance initiatives on the rise and increasing mandates for public reporting of hospital data, it's critical that the medical record accurately reflect the severity of illness and the services provided to your patients.
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Regular audits and continuing education are the keys to a successful documentation assurance program, says Liz Youngblood, RN, MBA, vice president, patient care support services at Baylor Health Care System in Dallas.
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"When I conduct an initial review of the chart, I read it from the beginning, like a story starting with the emergency department notes, through the history and physical and start building a story from a clinical standpoint.
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An emergency physician is managing an acute myocardial infarction, arranging for a patient transfer, sewing up a laceration, and putting in a chest tube, with 20 people still waiting to be seen in the waiting room.
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Placenta accreta can represent a real clinical conundrum, especially if it is unrecognized before delivery.
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A few studies have suggested that we tend to underestimate blood loss during deliveries and cesarean sections. A group from Louisiana State University has addressed this issue again in a very clever way.
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Curtis and colleagues from the University of Alabama at Birmingham measured the rate of hip fracture among women who discontinued bisphosphonate therapy compared with women who remained on treatment.
