• Revenue Cycle Management
  • COVID-19
  • Reimbursement
  • Diabetes Awareness Month
  • Risk Management
  • Patient Retention
  • Staffing
  • Medical Economics® 100th Anniversary
  • Coding and documentation
  • Business of Endocrinology
  • Telehealth
  • Physicians Financial News
  • Cybersecurity
  • Cardiovascular Clinical Consult
  • Locum Tenens, brought to you by LocumLife®
  • Weight Management
  • Business of Women's Health
  • Practice Efficiency
  • Finance and Wealth
  • EHRs
  • Remote Patient Monitoring
  • Sponsored Webinars
  • Medical Technology
  • Billing and collections
  • Acute Pain Management
  • Exclusive Content
  • Value-based Care
  • Business of Pediatrics
  • Concierge Medicine 2.0 by Castle Connolly Private Health Partners
  • Practice Growth
  • Concierge Medicine
  • Business of Cardiology
  • Implementing the Topcon Ocular Telehealth Platform
  • Malpractice
  • Influenza
  • Sexual Health
  • Chronic Conditions
  • Technology
  • Legal and Policy
  • Money
  • Opinion
  • Vaccines
  • Practice Management
  • Patient Relations
  • Careers

Documenting a visit after a hospital stay

Article

Coding for a visit after a patient's recent hospital stay poses a unique challenge. Find out the answer to this pressing coding question.

A: When a patient stays in the hospital for more than 48 hours and is discharged, even if a transfer to another facility is involved, your note should recapitulate the reason for the hospitalization and include significant findings; the procedures or treatments given; and the principal, secondary, and final diagnosis(es). Do not use symptoms unless specified as undiagnosed, but include the patient's discharge status as well as specific instructions to the patient and/or family.

ADMISSION AND DISCHARGE

When a patient is readmitted after a procedure in another facility 2 days later, document this in an admission note in the patient's medical record within 12 hours, if possible. The admission note should contain the reason for admission; provisional diagnosis(es); and a statement regarding the initial assessments of the patient that includes candidacy for a surgical procedure, where appropriate, or any other procedure that involves a degree of risk. The admission note also should have a relevant H&P.

HISTORY AND PHYSICAL

A complete H&P for inpatient admissions and procedures performed in an operat-ing room should include identification data; chief complaint; details of present illness, including an assessment of the patient's relevant medical/social/family history; a review of the inventory of body systems; physical examination; mental status; current medications; allergies; vital signs; and a diagnosis or problem list with a plan of care.

An H&P for children and adolescents should include an evaluation of developmental age; consideration of educational needs and daily activities as appropriate; a parent's report or other documentation of immunization status; family/guardian expectations for and involvement in the assessment, treatment, and care of the patient; and the psychosocial needs as appropriate to the patient's age. This may be part of the H&P or the initial nursing assessment.

Some hospital bylaws state that if you performed an H&P within 30 days before the patient's admission, you may include a copy of the report in the patient's medical record provided you add a note stating that no changes occurred or detailing any changes that occurred. If your hospital's bylaws do not include this information, seek clarification at the hospital's medical staff office.

Related Videos
© drsampsondavis.com
© drsampsondavis.com
© drsampsondavis.com
© drsampsondavis.com
Mike Bannon ©CSG Partners
Mike Bannon ©CSG Partners