If the nursing documentation in your emergency department is lacking key information, your facility may not be getting all the reimbursement it deserves. More ominously, inadequate nursing documentation can open the door for costly legal action down the road. Read More

You should include the following items in your documentation, according to Candace E. Shaeffer, RN, MBA, vice president of coding/quality management at Lynx Medical Systems in Bellevue, WA. Read More

Because the practice of placing a patient in restraints or somehow isolating that patient is scrutinized so carefully — not just by the Centers for Medicaid & Medicare Services and the Joint Commission but by internal hospital committees and patients’ families as well — it’s vitally important for you to be able to document what you did, why you did it, and how often you followed up. Read More

It’s no secret that the fast-paced and often crowded environment at many emergency departments can pose problems not faced in other, more sedate levels of care. And it’s perhaps no surprise that many of the factors that cause inadequate documentation in the ED also can lead to medication errors. Read More

Because the ED typically is organized to deliver prompt, life-sustaining care, its role, purpose, and function differ from other patient care areas, according to Rockville, MD-based U.S. Pharmacopeia. The combination of interruptions, intense pressure, and a fast-paced environment can lead to medication errors and fewer error interceptions. Read More

A member of the steering committee of The Leapfrog Group, a Washington, DC-based patient safety organization, said the committee is developing plans to help hospitals recoup some of the money they invest in changes to meet Leapfrog recommendations. Read More

It’s a common practice to benchmark physician-billing patterns against those of peer groups. Unfortunately, benchmarking against such data is misleading, since it is based upon three incorrect assumptions. Read More

When does critical care become just another emergency department visit? When you fail to document it properly. You may do all the right things and have a patient in crisis, but if the paperwork isn’t done properly, you don’t get paid for your efforts. Read More

Agreement in coding of emergency charts between coding agencies used by one hospital system was only poor to fair, and the distribution of assigned CPT-4 codes was significantly different among the agencies, according to a study from William Beaumont Hospital System in Royal Oak, MI, published in the Annals of Emergency Medicine. Read More

The Department of Health and Human Services' Centers for Medicare and Medicaid Services has issued a checklist to help health care providers who do business electronically and their business partners to comply with the administrative simplification requirements of the Health Insurance Portability and Accountability Act. Read More