You can save thousands by auditing patient charts

Over a year, how would you like to add $9,863 to your ED’s bottom line by catching missed charges for supplies or wrong acuity levels? Virginia R. Keusch, RN, clinical manager of the emergency and cardiopulmonary departments at Mecosta County General Hospital in Big Rapids, MI, accomplished this with two ED nurses by auditing about 10% of patient charts, or about six daily.

"We are usually looking at different things; they look for missed charges, and I look for reimbursement and coding issues," she explains.

For example, a nurse may document that a splint was used but forget to note that an elastic bandage was used to secure it, she explains. Recently, when a critical patient’s chart was reviewed for accuracy, Keusch found that missed items amounted to more than $300.

If problems with documentation are identified, this information is shared with individual nurses via one-on-one reminders. "We stay away from blanket’ memos or statements," she says. "I believe they do more to demean the people who are not having issues than to help the one that has made an oversight."

If a nurse is making a large number of documentation errors, the following steps are taken:

  • The nurse is given a timeline to improve.
  • The nurse is told the amount of lost revenue due to errors.

"Often, just bringing that to their attention is all they need," says Keusch. "For a nurse who feels they are too busy to pay attention to billing, I have equated the loss to nurse wages to show that if we are accurate, we could afford to have X amount of extra staff."

• Obstacles are identified.

If a nurse is making repeated documentation errors, the process is examined. "We make sure we don’t have some odd work-around that is making an obstacle for that employee," says Keusch. "Often, we are able to make a change in a form that makes it clearer."

For example, nurses often forgot to charge for the supplies used for an intravenous (IV) start, so the process was changed. "We are planning to use more explosion’ charges where the staff mark the IV start. Then, behind the scenes in the billing module, it explodes out to include supplies such as wound dressings and tape," she says. "This eases up on nurse time in hunting down charges." 

The most frequent inaccuracy is charging a casting charge when actually the procedure was splinting, which is roughly a $140 difference. To address this, the terminology on the charge sheet was changed from "cast" to "practitioner-applied cast" to make it less likely that nurses will check this box, since nurses don’t apply casts, explains Keusch.

Auditing also can pinpoint overcharges, such as an item nurses intended to use but didn’t, such as pacer pads, says Keusch. "If we can’t find an order or documentation that they used the item, we adjust the bill," she says.

[Editor’s note: Do you have a cost-cutting tip to share with ED Nursing readers? If so, please contact Staci Kusterbeck, Editor, ED Nursing, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail:]


For more information on auditing charts, contact:

Virginia R. Keusch, RN, Critical Care Services Clinical Manager, Emergency and Cardiopulmonary Departments, Mecosta County General Hospital, 405 Winter Ave., Big Rapids, MI 49307. Telephone: (231) 796-8691, ext. 4381. Fax: (231) 592-4421. E-mail: