Question: How should I document relief if another doctor takes over?
Three tips for documenting relief
- A little information does a lot. Change of care can be documented in a few words. Example: A note that ”A” signs out to Dr. ”B” at 3.30 with signatures of both providers is sufficient. That’s what an auditor would expect on a paper record. On an electronic record, the auditor might look for a note that the provider taking over has been briefed on the case.
- Make sure there’s a backup in place. R. nurses also should document whenever a different anesthesiologist comes in or leaves the O.R. This is another way auditors can spot when you aren’t documenting relief.
- Don’t leave a gap. When providers relieve one another, the record should not indicate a gap of a minute (or more). A gap in time looks like the provider left the patient unattended and it can cause a loss in the minutes billed.
Note: Make sure your electronic medical record system isn’t causing problems. An EMR that requires one provider to log out before another logs in can create the appearance of a gap.