Returning from a holiday weekend - I'm just curious as to how many of you do retro-admission reviews from the weekends? Do you review your Saturday/Sunday admissions along with your Monday admissions?
we do the same as below. We may not be able to complete all the admissions from the weekend. So, we prioritize those cases that are Medicare.
Stacy Vaughn, RHIT, CCS Data Support Specialist/DRG Assurance Aurora Baycare Medical Center 2845 Greenbrier Rd Green Bay, WI 54311 Phone: (920) 288-8655 Fax: (920) 288-3052
We review all admissions that occurred over the weekend.
If there were short stay admits already discharged and if it is still possible to effect change (ie, query the physician and obtain a response -- still on service Monday, etc.) we will also attempt to review weekend discharges. These discharge reviews are a second priority after the pts still in-house.
On Monday we review Friday, Saturday and Sunday admissions. If there are any Monday admissions on our census we will review them also. Our census prints anywhere between 3 and 5 AM - anyone admitted after that time will appear on the following days census.
Just to reply to the forum - we review weekend admissions that are still in-house on Monday. Just for "record-keeping" in our CDI Software I will usually enter a short explanation as to why the patient was not reviewed - "LOS 1 day", "Patient discharged before review", occasionally I will enter "CDS-Holiday" or something like that.
We do not perform the queries on discharge, our coders do that if necessary.
Just wondered if we were all spinning our wheels Monday morning with things we do not have control over?
On Monday we review the admit/discharged charts from the weekend. We find many charts that were in the wrong status and we get those corrected before being billed. That wasn't our initial focus but it has proven to be very helpful. Over the past 3yrs the average no. of charts is around 6.
If they are still in house, I review them; otherwise, as I am a team of one, I'm not expected to do so. If I am all caught up and have nothing else to do, I might go back and do retro reviews on the short stays from the weekend. I have to do all the queries anyway, regardless of whose brain--mine or the coders'--initiates them. If the coder wants a query, she sends it to me and I review the chart so that I understand what she is asking for before I approach the physician.
We don't do retro reviews. On Mondays we review admits for Thursday/Friday, and on Tuesdays, we review admits for Sat/Sunday, but do not do retros if the patients are already discharged;
If a patient is discharged before we have a chance to review the chart - we do not retro review either. If coding finds that a query is necessary - they will forward the chart for the query request.
We do review the charts from the weekend. Many times there are opportunities for a quick and easy clarification on a patient that came and went over the weekend. Example: COPD exac pt came in on Friday, quickly stabilized and discharged home on Sunday. MD documents pt with history of CHF stable at this time. Home CHF meds continued, BNP checked but not elevated, daily weights by nursing staff. We would then clarify the chronic heart failure for the cc.
Dee Schad, RN Clark Memorial Hospital Jeffersonville, IN 47130
Comments
admissions from the weekend. So, we prioritize those cases that are
Medicare.
Stacy Vaughn, RHIT, CCS
Data Support Specialist/DRG Assurance
Aurora Baycare Medical Center
2845 Greenbrier Rd
Green Bay, WI 54311
Phone: (920) 288-8655
Fax: (920) 288-3052
If there were short stay admits already discharged and if it is still possible to effect change (ie, query the physician and obtain a response -- still on service Monday, etc.) we will also attempt to review weekend discharges. These discharge reviews are a second priority after the pts still in-house.
Don
and were discharged over a weekend I do not review them.
Robert
Robert S. Hodges, BSN, MSN, RN
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"Anyone who has never made a mistake has never tried anything new."
-Albert Einstein
We do not review discharged ones from the weekend either.
Stacy
On Monday we review Friday, Saturday and Sunday admissions. If there are any Monday admissions on our census we will review them also. Our census prints anywhere between 3 and 5 AM - anyone admitted after that time will appear on the following days census.
in-house on Monday. Just for "record-keeping" in our CDI Software I
will usually enter a short explanation as to why the patient was not
reviewed - "LOS 1 day", "Patient discharged before review", occasionally
I will enter "CDS-Holiday" or something like that.
We do not perform the queries on discharge, our coders do that if
necessary.
Just wondered if we were all spinning our wheels Monday morning with
things we do not have control over?
N. Brunson, RHIA
Clinical Documentation Specialist
Bay Medical Center
Clinical Documentation Integrity Specialist
Waterbury Hospital
203 573 7647
Renee
Linda Renee Brown, RN, CCRN, CCDS
Clinical Documentation Specialist
Arizona Heart Hospital
Dee Schad, RN
Clark Memorial Hospital
Jeffersonville, IN 47130