{"id":3996,"date":"2018-11-08T08:58:52","date_gmt":"2018-11-08T08:58:52","guid":{"rendered":"https:\/\/www.saince.com\/?p=3996"},"modified":"2023-05-18T05:18:09","modified_gmt":"2023-05-18T09:18:09","slug":"better-outpatient-cdi-for-emergency-care-wound-care-and-total-knee-replacement","status":"publish","type":"post","link":"https:\/\/www.saince.com\/blog\/better-outpatient-cdi-for-emergency-care-wound-care-and-total-knee-replacement\/","title":{"rendered":"Better Outpatient CDI For Emergency Care, Wound Care and Total Knee Replacement"},"content":{"rendered":"<p><span lang=\"EN\">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. \u201cClinical documentation is at the core of every patient encounter,\u201d says the American Health Information Management Association (<a href=\"http:\/\/www.ahima.org\/topics\/cdi\">AHIMA<\/a>). 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. <\/span><\/p>\n<p><span lang=\"EN\">A <a href=\"https:\/\/ahima.confex.com\/ahima\/90am\/meetingapp.cgi\/Session\/12530\" class=\"broken_link\">recent presentation<\/a> 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:<\/span><\/p>\n<p><b><span lang=\"EN\">Emergency Room (ER)<\/span><\/b><\/p>\n<p><span lang=\"EN\">Better ER documentation centers around four key questions:<\/span><\/p>\n<ol>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Does documentation support the most appropriate visit level?<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Does documentation support the billable services?<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Does documentation accurately report staff present for care provided?<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Does documentation accurately report the amount of time staff spends with critical patients?<\/span><\/li>\n<\/ol>\n<p><span lang=\"EN\">When it comes to supporting the most appropriate visit level, what severity is being documented?<\/span><span lang=\"EN\">\u00a0<\/span><\/p>\n<ul>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Self-limited or minor<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Low severity<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Moderate severity<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">High severity, requires urgent evaluation by the physician but does not pose threat to life or physiologic function<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">High severity, poses an immediate significant threat to life or physiologic functions<\/span><\/li>\n<\/ul>\n<p><span lang=\"EN\">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.<\/span><\/p>\n<p><b><span lang=\"EN\">Wound Care<\/span><\/b><\/p>\n<p><span lang=\"EN\">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:<\/span><span lang=\"EN\">\u00a0<\/span><\/p>\n<ul>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Describe the type of wound, location and size<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Describe if the wound is a partial or full thickness wound<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Describe stages of pressure ulcers<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Describe depth of pressure ulcers<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Any undermining\/tunneling\/sinus tract<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Drainage, type, amount or odor<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Various types of tissue in wound bed<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Wound edges and surrounding tissue<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Indicators of infection and pain<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Document interventions for healing and conditions that would affect healing<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Current topical treatment plan, response to treatment, modifications to plan, implementations of new orders, reasons for not changing treatment plan, referrals<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Document any education given to patient and caregiver<\/span><\/li>\n<\/ul>\n<p><b><span lang=\"EN\">Total Knee Replacement<\/span><\/b><\/p>\n<p><span lang=\"EN\">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:<\/span><span lang=\"EN\">\u00a0<\/span><\/p>\n<ul>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">A low anesthesia risk<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Few or no comorbidities<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Family at home to support<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Patient can tolerate rehab in an outpatient facility or at home<\/span><\/li>\n<li><span lang=\"EN\"> <\/span><span lang=\"EN\">Physician expects the patient to need fewer than two nights of hospital care<\/span><\/li>\n<\/ul>\n<p><span lang=\"EN\">For more information, contact Saince about PracticePerfect, a platform to help you address outpatient and ER CDI. <\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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. \u201cClinical documentation is at the core of every patient encounter,\u201d says the American Health Information Management Association (AHIMA). The association goes on to say that a meaningful documentation process must [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[40],"tags":[],"class_list":["post-3996","post","type-post","status-publish","format-standard","hentry","category-outpatient-cdi"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v20.13 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Better Outpatient CDI For Emergency Care, Wound Care and Total Knee Replacement -<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.saince.com\/blog\/better-outpatient-cdi-for-emergency-care-wound-care-and-total-knee-replacement\/\" \/>\n<meta property=\"og:locale\" content=\"en_GB\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Better Outpatient CDI For Emergency Care, Wound Care and Total Knee Replacement -\" \/>\n<meta property=\"og:description\" content=\"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. \u201cClinical documentation is at the core of every patient encounter,\u201d says the American Health Information Management Association (AHIMA). The association goes on to say that a meaningful documentation process must [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.saince.com\/blog\/better-outpatient-cdi-for-emergency-care-wound-care-and-total-knee-replacement\/\" \/>\n<meta property=\"article:published_time\" content=\"2018-11-08T08:58:52+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2023-05-18T09:18:09+00:00\" \/>\n<meta name=\"author\" content=\"admin\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"admin\" \/>\n\t<meta name=\"twitter:label2\" content=\"Estimated reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" 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