Stephen T. Pittenger, DVM, DABVP 9/20/2013

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1 Dr. Stephen Pittenger Memorial 610 Hospital for Animals Houston, Texas How does this differ from the Outpatient setting? Longer admission Less inherent structure to visits More staff interact with the record More items and services to order/record and invoice Inpatient admissions occur for 4 basic reasons: Outpatient admission to hospital Day admission (extended outpatient) Scheduled procedures Emergency admission Where does everything go? How do I make sure we charge for everything that we do? How do I make sure everything actually gets done? Medical Records input needs to take care of billing. This avoids double entry (sometimes triple entry) Realize that many systems are transaction oriented, with the medical record creation being somewhat secondary. This is okay, we can make this work just fine. Some medical record driven systems are not so good at fee capture... Inventory is inventory (with a few exceptions) Qty delivered is placed into the record in some way. The route and the reason for delivery is clear. The exact medication (including strength) is obvious. This step must take care of the billing aspect simultaneously. Practice Builder

2 Here is the way.... Decide on appropriate conventions such as where to record weights (preferably so that the patient record is updated to the current weight, don t just squirrel it away somewhere). Decide on your nursing examination notes versus doctor s notes. POMR is the best way to go. Make sure your problem list is being updated along the way and the set is driving the medical record SOAP each day. Diagnosis coding is appropriate when diagnoses are made (may need to adjust for granularity over the length of the visit). When the chart is printed, it is readable by any other clinician or practice. When the medical history is searched, you can easily find things. When trying to look for particular information, you can find it and view it easily to make future decisions based on past historical findings. It allows you to go home earlier than before I use it when I am at my desk. Phone call summarizations Long narratives Referral Letters New surgery reports Conference Manuscripts Client Data Patient Data Drug Name Sig Sign It Practice Builder

3 Generation of the radiograph imprinting card through the computer improves the overall readability of the card, but also creates a check and balance in the imaging department as well. Since the card creation is linked to the medical record entry for the radiograph(s), the appropriate charges will be entered. Print to regular paper on laser printer fold in half and place on imprinter face up. Have the AVImark system talk to your PACS through the Modality Worklist function and deliver the study parameters directly to the Image Acquisition Software Laboratory submissions are problematic for many practices. Occasionally, practices submit samples to a reference lab, lbbut fail to bill bllthe client for the submission. Practice Builder

4 Two simple processes will prevent omission from the medical record and therefore the billing cycle: EHR generated laboratory submission forms ensure that the proper information is contained on the submission form. EHR generated labels are used to label the samples. The standard in the practice is transformed to a simple check and balance No label or submission form and the sample is not released to the laboratory. Any in house lab test also generates a label Label is placed on the machine while the sample is running (lets us know who is being run). Allows the doctor to order lab tests from the examination room. Practice Builder

5 Except in emergency situations, all controlled substances must be labeled with a software generated prescription label. This label would include the client and patient name as well as the medication, amount, route and reason for administration. This would insure that the appropriate information has been captured for placement in the controlled substances log, which may also be in electronic format. The attending clinician prescribes intravenous fluid therapy. Since this is considered a dangerous drug, a prescription label lblh should ldbe affixed to the bag designating the patient and administration directions. If all fluid bags are labeled in the hospital, the appropriate entries into the medical record will be made and billing for those fluids is appropriately captured. Practice Builder

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