Editor's Picks By defensive charting, we mean protective. Who are you protecting? With proper documentation, you protect your patient and yourself. Chart only what you see, hear, feel, measure, count, and experience; not what you suppose, infer, or assume. Chart as if the words you write reflect the actual and complete record of the care rendered, because they must. Chart as if every word could one day be scrutinized in a court of law, because it can. One nurse leader talks about how the nursing profession is set to evolve in the face of healthcare transformation. We’re in the early planning stages of our 2020 nursing books and we need your help! Please take a few short minutes to complete our brief survey. Your feedback will help us develop products, support, and guidance for you and your colleagues.
Click here or enter this URL into the address bar of your browser to take the survey: https://www.surveymonkey.com/r/DYR68TD Marketing Spotlight JustCoding's Drug Administration Capture and Audit Tool provides multiple critical tools for nurses, providers, and drug administration staff. It includes an easy-to-follow pocket card reference that will help coding staff report the most accurate CPT codes per the drug administration hierarchy. The back of the pocket card includes a list of nursing interventions and procedures that are separately identifiable. Having this information immediately available will let coders and billers quickly determine when to count these interventions as separate procedures.
In addition to the pocket card, this resource includes an electronic downloadable component that will allow providers to set up an IV medical administration record (MAR) within an EMR. Staff will be able to quickly and efficiently pull medications from the discharge MAR with start and stop times, as well as the route of administration. This tool will allow billing or auditing staff to instantly generate reports when looking for justification for administering and charging a certain drug (e.g., chemotherapy). The download includes an Excel workbook that details a work plan for implementing the tool, along with sample logic, reports, and easy-to-understand instructions.
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