INDEX

Documentation

Table of Contents:

• Video Tutorials

• Attending Documentation

• APPs (Midlevels)

• Critical Care

• Deficiency Penalty

Cross References:

• Computer Orientation

• Death Note

• Downtime

• Procedural Sedation

• Trauma Procedures

For a video tutorial on PowerNote documentation, please see the Orientation page.

The following video is for new attendings working in the ED. It contains important information about co-signing charts with residents and midlevels as well as expectations regarding chart deficiencies.

With the exception of medical screening exams (MSEs), all patients seen by an APP must be staffed by an ED physician.

All APP notes should be forwarded to the appropriate attending, and the attending physician should include the following in the designated areas at the bottom of the note:

1. The APP attestation (clickable option), and…

2. A short summary of their personal assessment

Critical care billing requires 3 elements to be present.

1. A description of the critical nature of the patient’s disease.

2. A description of the interventions used to stabilize the patient.

3. A discrete numeric amount of critical time over 30 minutes.

Use the designated area of the ED Physician Note (or ED Addendum) for documenting “Critical Care Time”. (It’s a required field)

For resident notes, attendings must ensure that the 3 necessary elements for CC billing are present and otherwise simply click the “Critical Care” attestation.

For APP notes, it works similarly but in addition to the “Critical Care” attestation, the attending must document their own short note below the attestation discussing the critical nature of the patient’s disease and the care delivered.

If a physician has 10 or more charts on any deficiency list for 2 consecutive weeks, the physician will be deducted $250 from their PRA account. An additional $250 will be deducted from their PRA each subsequent week it is not corrected and any receipts submitted during that time will be denied.

• The count of “10” is not a sum of the lists (eg. Someone with 5, 6 and 4 counts on all three lists would not be hitting the threshold. Someone with 11 on the professional list for one week and 10 on the hospital list the next week WILL hit the threshold.).

• Deficiencies due to un-forwarded APP or resident charts will NOT count towards the penalty threshold. If someone has 10+ deficiencies listed for 2 consequentive weeks (which might include un-forwarded notes), and is at risk of having the penalty applied, there will be a final review before processing the penalty to ensure un-forwarded notes are not counted.

KEYWORDS: documentation, powernote, note, critical care time, app, midlevel