Medhost edis documentation tip sheet

DOCUMENTATION DEFICIENCY FEEDBACK is an integral component of ensuring that you are
not losing critical revenue dollars. Here are some tips on decreasing most common documentation
deficiencies in the emergency department.

1. DOCUMENTATION DEFICIENCY FEEDBACK is an integral component of ensuring that you are
not losing critical revenue dollars. Here are some tips on decreasing most common documentation
deficiencies in the emergency department.
You Don’t Get Paid For
What You Do.
You Get Paid For What
You Document.

2. Decrease these most common documentation deficientcies in your
emergency room department for a revenue boost.
EKG documentation
EKG documentation must include rhythm or rate, axis, intervals, comparison to a prior EKG,
summary of clinical condition and adequate documentation of the HPI and ROS chart components.
History of the present illness (HPI)
History of the present illness (HPI) and review of systems (ROS) chart components should include
onset, location, duration, severity.
Procedure notes
Adequately- document procedure notes to ensure that you will get maximum reimbursement. Most
common missed procedures are laceration repair, lumbar puncture and central venous line placement.
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3. Decrease these most common documentation deficientcies in your
emergency room department for a revenue boost.
Fracture documentation
Fracture documentation should include bone identification, displacement or non-displacement
identification, stabilization method, pain treatment, orthopedic consultation/referral, evaluation of
other sites/injuries and fracture care.
Splint
Medicare documentation for splint should support placement of splint and checking of the splint, and
you must note that it was actually placed not just document that the splint will be placed.
Critical care time
In order to charge for one hour of critical care time, at least 30 minutes of critical care time must
be documented. Time spent performing separate reportable procedures or services should not be
included in the time reported as critical care.
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4. MEDHOST Emergency Department Information System delivers
fewer medical errors, more revenue for hospitals, faster patient
throughput and higher patient satisfaction scores.
MEDHOST EDIS applies a Charge Capture methodology
in which every element of care documented is captured
and charged with no additional steps and no subjectivity or
interpretation by clinicians.
For more information about MEDHOST EDIS, contact us
today by email at [email protected], by phone at
1.800.383.6278 or at http://www.medhost.com/offerings/edis.
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