Pandemic – Peril and the promise

Morning musings from a CEO

Pandemic – Peril and the promise

Jun 15, 2020 by Raghu Vir 0 Comments

The world right now is hurting. And it is hurting really bad. There is a lot of physical, emotional, and economic pain all around. This pain is accentuated with fear. Fear of facing the unknown. Fear of being helpless. Health workers are helplessly watching their patients die in front of their eyes. Children are helplessly watching their parents succumb on FaceTime. The world is now firmly in a grip of fear and gloom.

But behind all this fear and sadness I see hope. I see promise.

I see hope because whenever humanity faced a calamity in the past, either natural or man-made, when it came out on the side, the world became a much better place. For everyone. Each and every event that we faced in the past, be they world wars or natural disasters, brought a lot of pain along with them but after the event they also elevated humanity as a whole.

The Gita, the holy book of Hindus, says that good and bad are two sides of the same coin. One cannot exist without the other. Sort of Yin and Yang of the Chinese philosophy.

This pandemic brought a lot of pain. It pushed a lot of people out of business. More than 40 million Americans lost their jobs. Food lines were unimaginably long.  Everyone is scared. Everyone is hurting in some way or the other. But coming out of all this suffering and pain, I’m seeing an increased feeling of compassion among people. Out of this common suffering I see camaraderie that I never saw before. Unemployment made people look deeper within themselves. The whole climate was emotionally charged.

Then George Floyd died. That triggered an outpouring of emotion. People spontaneously took to the streets, not just in big cities but also in small towns and remote corners. Not only here but all over the world. It united us as a humanity. We felt other person’s pain like we never felt it before. We felt compassionate. We saw the long-standing inequalities in the system. We started on a path to fix it. Events like George Floyd’s death happened before the pandemic too. But the reaction was sporadic. It was temporary. But this time it is different. There is something in the air this time that smells different. We are embarking on a path to make America a better nation than it already is. As a human race, we are starting to feel more united than before.

This time it is different. The scientific community is breaking down borders and collaborating in an unprecedented manner.  They are tearing apart bureaucracies. Putting aside their personal agendas. Working fearlessly and tirelessly towards a common goal for the benefit of humanity. They are realizing the power of cooperation and sharing. Governments are as usual trying to put brakes on this by making it a competitive race. I am hoping that better sense will prevail.

The earth is healing as well. We are now more open to noticing how we have been plundering the natural resources all these years. We have already reached the tipping point in climate change. We were almost at a point of no return. With this pandemic, we hit the pause button. We are seeing palpable change even in this short period when we hit the brakes on our emissions. I am hopeful that as a human race we can continue to let the planet heal.

Families are healing as well. Families are spending time together. They are talking with each other. They are having verbal conversations instead of texting to each other from across the room. They are eating together, playing together, staying together and coming together. When families stay together, communities stay together. When communities heal, nations heal.

Fighting and terrorism across the world has come down quite a bit. In this process a lot of lives has been spared. I hope they use this time to introspect and come together because the virus does not play favorites. When there is a common enemy, everyone comes together.

Hence, I see promise on the other side of this pandemic. To deliver a bundle of joy, the mother goes through a lot of pain.

I am optimistic. I am hopeful. I am human.

Clinical Documentation Improvement, Outpatient CDI

When Pursuing CDI, Using Risk Adjustment Is Vital

Mar 1, 2019 by admin 0 Comments ,

As healthcare has moved away from fee-for-service reimbursement models toward a more value-based system, the idea of using risk adjustment to account for individual patient risk and chronic conditions has become far more important for providers seeking to maximize quality of care.

In today’s healthcare environment, providers are often required to fight simultaneous battles on several fronts. For those pursuing clinical documentation improvement (CDI), they must balance sometimes-conflicting regulatory demands, workflow needs, etc. Further exacerbating the problem is the persistent shift of care provision to the ambulatory setting and the increasing demands it places on provider organizations.

As we have discussed in previous blog posts, outpatient CDI efforts face a number of unique challenges, such as decidedly larger case volumes than most inpatient settings and far shorter clinical visits. These shorter visits produce less usable patient data and offer a condensed window during which multiple team members must work in synchrony—accurately and efficiently—to gather that data. Outpatient providers must also go further, factoring in risk adjustment for each individual in their larger patient populations as well.

Often, problems with risk adjustment appear when inaccurate or incomplete diagnosis coding slips through the documentation workflow. For instance, failure to capture patients’ Hierarchical Condition Categories (HCCs)—and recapture year-over-year—can greatly skew risk scores for individual patients and potentially the overall population. Such mistakes can filter downstream to errors in patient care and increasing claim denials and, potentially, wreak havoc on pay-for-performance reimbursements.

This dynamic puts increased pressure on physicians to capture correct documentation at the point of care—getting it right the first time without a great deal of revision. Many have addressed the issue through Computer Assisted Physician Documentation (CAPD), which provides a number of CDI features. CAPD improves accuracy and lessens physicians’ burdensome workflow by precluding the need to rehash previously captured documentation.

The goal of these products is to allow physicians to complete patient care documentation faster and spend more time with their patients. Unfortunately, many traditional products, which were designed for inpatient settings, lack effective integration of risk adjustment. As a result, many providers are prevented from seeing the most accurate picture of the population they serve—and value-based care programs are not as successful as they could be.

To learn about PowerSpeak+RAPID – a CAPD platform combining powerful front-end medical speech recognition software (PowerSpeak) and Risk Adjusted Physician Documentation (RAPID) – contact Saincesaince inc logo

Medical Transcription

Study: Burnout is a Public Health Crisis, Support and Easing EHR Usability Should Be the Focus

Feb 28, 2019 by admin 0 Comments

Sooner or later, the consequences of physician burnout will hit everyone where it hurts, a new study highlights.

The report from Harvard’s T.H. Chan School of Public Health, the Harvard Global Institute, the Massachusetts Medical Society, and the Massachusetts Health and Hospital Association examines the many burdens today’s doctors face, often in the absence of adequate support. Further underscoring burnout’s status as an urgent and growing public health crisis, the researchers focus much of their attention on electronic health records (EHRs)—particularly the onerous demands they often create.

Electronic Medical Records

As we’ve previously discussed, the amount of time physicians spend inputting data into EHRs continues to be an issue for hospital leaders, healthcare regulators and, most important, the doctors themselves. Multiple studies released last year pointed to EHRs as the leading cause of burnout, listing strategies—such as dictation and transcription services—for decreasing EHR’s demands on physicians’ time.

Rather than taking a deep dive on specific EHR solutions, the Harvard study seeks to drive home the urgency of the issue. And in acknowledging similar studies, the researchers seek to add their voices to the swelling chorus demanding action.

Among the research they cite is the 2018 Survey of America’s Physicians Practice Patterns and Perspectives conducted by Merritt Hawkins on behalf of the Physicians Foundation, in which an astounding 78 percent of physicians reported feeling burnout at least some of the time. As the researchers note, no stakeholder escapes harm.

Physician burnout impacts patient health and well-being by increasing medical errors and decreasing patient experience scores. Likewise, a separate crisis emerges for hospitals as physicians cut back their hours.

According to the study, “every one-point increase in burnout (on a seven-point scale) is associated with a 30–40 percent increase in the likelihood that physicians will reduce their work hours in the next two years.” Beyond reshuffling the workload, the cost of recruiting and replacing a physician can range from $500,000 to $1 million, according to a 2017 report in JAMA Internal Medicine.

For their part, doctors continue to call for new strategies at every opportunity. As we quoted one surgeon last year, “Develop a better and more user-friendly EHR. It shouldn’t take 20 minutes to do something that dictation takes three minutes.”

For help understanding how a state-of-the-art dictation and transcription platform can deliver proven benefits to physician practices, hospitals, integrated delivery networks (IDNs) and medical transcription services organizations (MTSOs) of all sizes, as well as successfully integrate with leading EHR systems, read about Saince’s Doc-U-Scribe product or contact Saince.saince inc logo

Clinical Documentation Improvement

When Pursuing CDI, Using Risk Adjustment Is Vital

Jan 8, 2019 by admin 0 Comments

As healthcare has moved away from fee-for-service reimbursement models toward a more value-based system, the idea of using risk adjustment to account for individual patient risk and chronic conditions has become far more important for providers seeking to maximize the quality of care.

In today’s healthcare environment, providers are often required to fight simultaneous battles on several fronts. For those pursuing clinical documentation improvement (CDI), they must balance sometimes-conflicting regulatory demands, workflow needs, etc. Further exacerbating the problem is the persistent shift of care provided to the ambulatory setting and the increasing demands it places on provider organizations.

As we have discussed in previous blog posts, outpatient CDI efforts face a number of unique challenges, such as decidedly larger case volumes than most inpatient settings and far shorter clinical visits. These shorter visits produce less usable patient data and offer a condensed window during which multiple team members must work in synchrony—accurately and efficiently—to gather that data. Outpatient providers must also go further, factoring in risk adjustment for each individual in their larger patient populations as well.

Often, problems with risk adjustment appear when inaccurate or incomplete diagnosis coding slips through the documentation workflow. For instance, failure to capture patients’ Hierarchical Condition Categories (HCCs)—and recapture year-over-year—can greatly skew risk scores for individual patients and potentially the overall population. Such mistakes can filter downstream to errors in patient care and increasing claim denials and, potentially, wreak havoc on pay-for-performance reimbursements.

This dynamic puts increased pressure on physicians to capture correct documentation at the point of care—getting it right the first time without a great deal of revision. Many have addressed the issue through Computer-Assisted Physician Documentation (CAPD), which provides a number of CDI features. CAPD improves accuracy and lessens physicians’ burdensome workflow by precluding the need to rehash previously captured documentation.

The goal of these products is to allow physicians to complete patient care documentation faster and spend more time with their patients. Unfortunately, many traditional products, which were designed for inpatient settings, lack effective integration of risk adjustment. As a result, many providers are prevented from seeing the most accurate picture of the population they serve—and value-based care programs are not as successful as they could be.

Power Speak - Speech Recognition and Reporting Software

To learn about PowerSpeak+RAPID—a CAPD solution that combines powerful speech recognition technology (PowerSpeak) with real-time risk adjustment using HCCs (RAPID), please contact Saince.

Dictation

Dictation: Giving Physicians a Break While Avoiding Costly Medical Errors

Dec 17, 2018 by admin 0 Comments ,

Overworked professionals, regardless of industry, are far more likely to make mistakes. For medical professionals, however, particularly when it comes to documentation, those mistakes risk profound repercussions for both medical providers and their patients. They’re also notoriously difficult to correct once they’ve been made.

Earlier this year, researchers from Johns Hopkins released a report pointing to medical errors as the third leading cause of death in the United States behind heart disease and cancer. From typos to incorrect dosing to misdiagnoses, the consequences of these mistakes can range from mundane to catastrophic—blamed for 250,000 to 400,000 deaths annually. Beyond medical mistakes, documentation errors can also wreak havoc in other areas of patients’ lives, such as when applying for life insurance.

Although completely eliminating such errors would require both industry and regulatory efforts of enormous proportions, providers can leverage a simple workflow strategy to safeguard against many of these mistakes. Dictation allows doctors to spend less of their time on documentation while sharing the workload with trained specialists who can process the records—ensuring accuracy and integrity are maintained.

medical dictation

As we recently highlighted, the advent of electronic medical records (EMRs), which originally heralded a new age of documentation ease and efficiency, actually created more administrative work for doctors. As a result, EMRs are cited in study after study as a leading factor in the twin epidemics of physician and nurse burnout. In many of those same studies, however, dictation and transcription have been highlighted as preferred strategies to make EMRs more physician friendly.

By relying on dictation, which can be seamlessly integrated into the EMR, physicians can get back to the reason they entered medicine—to care for patients. Because, as the Johns Hopkins researchers were quick to note, these errors rarely stem from poor medical care but rather a systemic problem that places undue—and out-of-scope—burden on chronically overworked doctors and providers.

A state-of-the-art dictation and transcription platform can deliver proven benefits to physician practices, hospitals, integrated delivery networks (IDNs) and medical transcription services organizations (MTSOs) of all sizes. To learn more about how these can be successfully integrated with leading EMR systems, read about Doc-U-Scribe or contact Saince.

EHR

EHRs, Documentation Leading to a Physician Burnout Crisis

Dec 11, 2018 by admin 0 Comments

Dictation and Transcription Improvements Cited as No. 1 Fix by Docs

When they were kids thinking about their future career, physicians didn’t dream of taking care of administrative record-keeping. They dreamed about taking care of patients.

But extensive documentation fatigue has become a leading concern for the healthcare industry. Just this week, the U.S. Department of Health and Human Services (HHS) released a draft strategy aimed at reducing the amount of time clinicians spend recording information in electronic health records (EHRs). Now there’s an open 60-day comment period for clinicians and others to provide feedback to the draft strategy.

The healthcare industry is waking up to the reality of doctors’ serious unhappiness with EHRs. Many physicians seems to agree with one emergency room physician who sees EHRs as “predominantly a billing tool, secondarily a compliance tool … [There are] too many boxes to click, too many irrelevant alerts, soft or hard stops which create alert fatigue. [There is] very little useful clinical decision support.”

EHR(Electronic Health Records)

 

And that unhappiness with the tools is leading to overall dissatisfaction. In a nationwide survey of 254 physicians from different specialties, physicians cite EHRs as the biggest contributing factor to burnout.

 

Incredibly, the amount of time physicians spend on administrative work has surpassed the amount of time spent with patients. A study published last year in Health Affairs reveals that physicians spend more of their time doing “desktop medicine” as they do seeing patients. Desktop medicine includes “communicating with patients through a secure patient portal, responding to patients’ online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results.” The study, which analyzed 31 million EHR transactions over four years by primary care physicians, shows that physicians are logging an average of 3.08 hours with patients and 3.17 hours on documentation every day.

With the demands for a more physician-friendly EHR, doctors have identified dictation and transcription as a preferred part of a better EHR solution. In the same survey where EHRs are blamed as the primary contributor to physician burnout, the No. 1 suggestion (17 percent) for fixing the problem was to add dictation and scribe features to EHRs. The second and third suggestions were not even solutions, but complaints, with 13 percent recommending that less time be spent in the system and 9 percent of respondents recommending that EHRs be replaced altogether.

The survey respondents were clear that the EHR workflow was not an innovation. Restoring dictation and transcription would help, respondents say. One orthopedic surgeon commented, “Develop a better and more user-friendly EHR. It shouldn’t take 20 minutes to do something that dictation takes three minutes.”

For help understanding how a state-of-the-art dictation and transcription platform can deliver proven benefits to physician practices, hospitals, integrated delivery networks (IDNs) and medical transcription services organizations (MTSOs) of all sizes, and successfully integrate with leading EHR systems, read about Doc-U-Scribe or contact Saince.

CDI Services

Getting CDI Compliance Right From the Start

Dec 4, 2018 by admin 0 Comments

For decades, countless market observers have warned of turmoil in the healthcare space. The upheaval and endless changes have created a cacophony of compliance requirements that leave healthcare providers—both new players and those pursuing improvements—scratching their heads about where to begin.

Organizations focusing on clinical documentation improvement (CDI) must foster an environment of effective compliance from the outset. If they hope to improve outcomes while also increasing revenues and reducing costs, those organizations must evolve CDI practices in support of shifting trends in reimbursement and its documentation requirements.

Get the Workflow Right, and Quality Will Follow

Outpatient CDI efforts are designed to address a variety of needs, including Hierarchical Condition Categories (HCC) capture, quality improvement, risk adjustment and more. Without thoughtful attention to the development of an efficient and effective workflow, however, these goals will compete as varied teams within the organization focus on different aspects.

For instance, what may appear to be an issue with quality may actually be an issue with documentation, or vice versa. Aligning staff around common goals—ensuring not only that they’re tracking the same metrics, but also prioritizing them in the same order—will help teams more quickly identify operational issues and their true causes.

Understand How CDI Efforts Affect Reimbursement

Whether through HCC capture, risk adjustment or other areas, CDI efforts are helping providers better adjust as the healthcare landscape shifts away from fee-for-service and increasingly toward value-based, alternative reimbursement models. But as noted above, leveraging these capabilities requires that teams align around these metrics and how coding and CDI work synergistically to achieve these ends.

clinical documentation improvement

Although fee-for-service remains the norm in many settings, even those once-reliable revenue streams are increasingly in jeopardy as a result of penalties surrounding poor quality or, conversely, failure on the part of organizations to properly code and capture reimbursement incentives. Capturing HCCs, in particular, is becoming a vitally important CDI task as the high-value diagnoses play a central role in risk adjustment—requiring ongoing, accurate documentation to reflect patient and population health risk.

Under this new payment paradigm, teams need to understand the relationship of day-to-day compliance, accuracy and the longitudinal effects they have on reimbursement and organizational efficacy.

Understand How Outpatient CDI Affects Population

If your organization has decided to address outpatient CDI, then many of the above strategies become even more vital. Streamlining workflows and organizational compliance is more challenging in the outpatient setting, which places a greater emphasis on effective intra-team cooperation and communication.

On the upside, however, by implementing effective outpatient CDI efforts as part of an overall CDI strategy, healthcare organizations can capture opportunities for medical necessity documentation as well as reduce error-driven medical necessity denials for patients.

For more tips on Outpatient CDI efforts, see our previous blog post. For help designing your organization’s CDI efforts or to learn about  PracticePerfect, a platform to help you address outpatient CDI, and Doc-U-Aide, a revolutionary platform for inpatient CDI, contact Saince.

Clinical Documentation

Safeguarding Cyber security Amid CDI Efforts

Dec 4, 2018 by admin 0 Comments

Original: Cyber security, Coding and CDI. Best practices to ensure best practices for cyber security are employed.

To say that the present state of healthcare cyber security poses a challenge for organizations undertaking clinical documentation improvement (CDI) efforts is a drastic understatement. Under the ever-present specter of costly cyber attacks, providers across the country continue to grapple with myriad, big-picture challenges such as information governance (IG), highly ambiguous government oversight and unstable compliance landscapes as well as shifting care settings.

Providers are required to adhere to strict security laws like HIPAA and HITECH while simultaneously acceding the regulatory demands of fluid information sharing contained in the 21st Century Cures Act—all while adapting to the logistical reality of increasingly frequent outpatient care delivery. Further intensifying those challenges, the shift to outpatient care means that greater volumes of protected health information (PHI) is being routed through ambulatory and other non-hospital settings, making them increasingly attractive targets for hackers. Additionally, a recent survey of medical coders also found that roughly one-third reported working remotely at some point, highlighting the potential vulnerability many providers face.

Healthcare Cyber Security

As they approach this challenging future, however, smart organizations can balance conflicting security and compliance concerns as well as inpatient and outpatient CDI initiatives by sharpening their focus in a few key areas.

Staffing and Training. In CDI, overwhelmed and under-trained teams are more apt to make costly mistakes. The same is true for cyber security. A misaligned and overworked team is a liability and leading cause of security breaches, but one with the tools, training and cohesion to efficiently manage their workflow is a powerful safeguard. The quickest way for any organization to promote quality and compliance—as well as security—while executing CDI efforts is to ensure its staff is trained well. Fostering alignment between providers, coding and other administrative staff must include education on common security risks, drills to identify weak points and emphasis on a culture where anomalies, breaches and prevention are openly discussed and addressed.

 

Emphasis on Accuracy and Clarity. Just as optimized CDI and streamlined organizational compliance—from the point of care to the submission of a claim—can reduce error-driven medical necessity denials, that same focus on accuracy and clarity can reduce security errors as well. As provider organizations seek to improve overall IG while also contending with growing troves of clinical data, enhanced CDI workflow is a necessary component strategy, intricately linked with all others.

 

Encryption of All Devices. Loss of mobile devices is a major cause of healthcare data breach, particularly in outpatient settings. As mobile devices become increasingly common tools in clinical documentation, ensuring that these devices and all computers are encrypted is an important, albeit not-HIPAA-required, step for organizations to take.

 

Vetting Vendors. An organization must safeguard its own internal protocols, but it must also ensure that its vendors—particularly those offering Software as a Service (Saas)—are taking all reasonable steps to protect data, confidentiality and security as well. It’s a must to understand a vendor’s risk assessments and require indemnification provisions and cyber security insurance in business associate agreements.

Designing your organization’s CDI efforts is a significant undertaking. To learn about  PracticePerfect, a platform to help you address outpatient CDI, or Doc-U-Aide, a revolutionary platform for inpatient CDI, contact Saince.

CDI Services

4 Factors to Consider for Optimizing CDI Workflows and Reporting

Nov 13, 2018 by admin 0 Comments

In recent years, the evolution of healthcare regulations has driven care away from the inpatient setting, while simultaneously increasing administrative and clinical documentation burdens for providers. As a result, many healthcare organizations have started expanding their clinical documentation improvement (CDI) efforts to outpatient settings by finding opportunities for increased reimbursement, enhanced quality, and improved patient satisfaction. However, this process also brings with it new challenges, far different from those faced with inpatient CDI.

Among the most explicit challenges that organizations face when pursuing outpatient CDI efforts are larger case volumes and markedly shorter clinical visits, which in turn generate far less usable data per patient. Additionally, that data is often collected by multiple team members during a narrow window, increasing the opportunity for costly errors. This dynamic underscores the need for efficient workflows that enable accurate, timely and comprehensive documentation.

Outpatient

As organizations explore optimizing outpatient CDI efforts, here are four factors to consider:

  1. Timely collaboration is crucial. Outpatient CDI efforts require a higher level of physician engagement, as well as an increased emphasis on workflow efficiency to ensure that accurate documentation is produced concurrently with the provision of care.

Fostering collaboration between providers, coding and other administrative staff is vital to any CDI effort’s success. These team members must understand how their roles align in order to support, create and sustain a culture of operational efficacy.

  1. Improved quality, care, and reimbursement go hand-in-hand. Streamlining organizational compliance from the point of care to the submission of a claim allows outpatient clinics and physician groups to optimize efforts with diagnosis coding and Hierarchical Condition Category (HCC) capture. It also helps them improve the Physician Quality Reporting System (PQRS) and Group Practice Reporting Option (GPRO) scoring and reduce error-driven medical necessity denials for patients.
  1. It’s critical to analyze and agree on goals and targets. A central component of fostering collaboration and improving metrics is first understanding specific organizational needs and identifying areas that need the most improvement. By focusing on collaborative resources in these areas, outpatient CDI efforts can be organized to ensure desired outcomes.
  1. Every organization’s needs will be unique. Key areas of improvement will vary from one organization to the next. Operational needs—from staffing to education to technology—will likewise be unique.

Designing your organization’s outpatient CDI efforts is a significant undertaking. To learn more about PracticePerfect, a platform to help you address outpatient and ER CDI, contact Saince.

Outpatient CDI

Better Outpatient CDI For Emergency Care, Wound Care and Total Knee Replacement

Nov 8, 2018 by admin 0 Comments

As care is increasingly delivered in an outpatient setting, it is critical that clinical documentation improvement (CDI) programs are developed to ensure compensation for care. “Clinical documentation is at the core of every patient encounter,” says the American Health Information Management Association (AHIMA). The association goes on to say that a meaningful documentation process must be accurate, timely and comprehensive of the services provided. The process should also engage physicians, so that they begin to associate documentation with a higher quality of care delivery rather than an interference in care delivery.

A recent presentation from the 90th Annual AHIMA conference showcased best practices for ensuring better outpatient CDI in the areas of emergency medicine, wound care and total knee replacement procedures. The presenters outlined these key practical considerations for documentation:

Emergency Room (ER)

Better ER documentation centers around four key questions:

  1. Does documentation support the most appropriate visit level?
  2. Does documentation support the billable services?
  3. Does documentation accurately report staff present for care provided?
  4. Does documentation accurately report the amount of time staff spends with critical patients?

When it comes to supporting the most appropriate visit level, what severity is being documented? 

  • Self-limited or minor
  • Low severity
  • Moderate severity
  • High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function
  • High severity, poses an immediate significant threat to life or physiologic functions

Supporting documentation is required for all elements of an ER visit, whether that means documenting the need for extra resources to deal with an intoxicated and combative patient, or the documenting the presence of a nurse in the room during a pelvic exam. The timeframe of patient time with nurses is a key element in being able to bill for critical care, with a requirement that at least 30 minutes of critical care services are provided and documented.

Wound Care

When it comes to wound care delivered in an outpatient setting, it is important to have clear and consistent documentation. Here are the key elements needed in documentation: 

  • Describe the type of wound, location and size
  • Describe if the wound is a partial or full thickness wound
  • Describe stages of pressure ulcers
  • Describe depth of pressure ulcers
  • Any undermining/tunneling/sinus tract
  • Drainage, type, amount or odor
  • Various types of tissue in wound bed
  • Wound edges and surrounding tissue
  • Indicators of infection and pain
  • Document interventions for healing and conditions that would affect healing
  • Current topical treatment plan, response to treatment, modifications to plan, implementations of new orders, reasons for not changing treatment plan, referrals
  • Document any education given to patient and caregiver

Total Knee Replacement

With total knee replacement procedures, it is important to note in the documentation that the procedure is appropriately offered in an outpatient setting. In order for the procedure to be taken off of the inpatient-only (IPO) list, it must meet the following criteria, all of which should be documented: 

  • A low anesthesia risk
  • Few or no comorbidities
  • Family at home to support
  • Patient can tolerate rehab in an outpatient facility or at home
  • Physician expects the patient to need fewer than two nights of hospital care

For more information, contact Saince about PracticePerfect, a platform to help you address outpatient and ER CDI.