提高儿科急诊科即时超声检查记录与计费准确性
Improving Point-of-Care Ultrasound Documentation and Billing Accuracy in a Pediatric Emergency Department.
作者信息
Ng Carrie, Payne Asha S, Patel Amit K, Thomas-Mohtat Rosemary, Maxwell Angela, Abo Alyssa
机构信息
Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine Houston, Tex.
Department of Pediatrics and Emergency Medicine, Children's National Hospital/George Washington University School of Medicine and Health Sciences Washington, DC.
出版信息
Pediatr Qual Saf. 2020 Jul 21;5(4):e315. doi: 10.1097/pq9.0000000000000315. eCollection 2020 Jul-Aug.
OBJECTIVE
The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative.
METHODS
We collected POCUS documentation and billing data from the EMR. Interventions included: (1) staff education and feedback, (2) standardization of documentation and billing, and (3) changes to the EMR to support standardization. We used P charts to analyze our outcome measures between January 2017 and June 2018.
RESULTS
Six hundred medical records of billed POCUS examinations were included. Complete POCUS documentation rate rose from 62% to 91%, and correct CPT code selection for billing increased from 92% to 95% after our interventions.
CONCLUSIONS
The creation of a standardized documentation template incorporated into the EMR improved complete documentation compliance.
目的
即时超声检查（POCUS）的操作和解读应在电子病历（EMR）中进行适当记录，并分配正确的计费代码。我们旨在通过实施质量改进计划，将完整的POCUS记录从62%提高到80%，并将正确的POCUS计费代码提高到95%或更高。
方法
我们从电子病历中收集了POCUS记录和计费数据。干预措施包括：（1）员工教育与反馈，（2）记录和计费的标准化，以及（3）对电子病历进行更改以支持标准化。我们使用P图分析了2017年1月至2018年6月期间的结果指标。
结果
纳入了600份已计费的POCUS检查病历。经过我们的干预后，完整的POCUS记录率从62%提高到91%，计费的正确CPT代码选择从92%提高到95%。
结论
将标准化记录模板纳入电子病历提高了完整记录的合规性。
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