07/27/16 – Documenting Relief

 

Question: How should I document relief if another doctor takes over?

Three tips for documenting relief

  1. A little information does a lot. Change of care can be documented in a few words.  ExampleA 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.
  2. 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.
  3. 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.

 


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