Abstract Category: Practice Innovation / Performance Improvement (PI)

Purpose: The purpose of this initiative was to achieve 100% compliance with IV site and IV fluid (IVF) end time documentation in the Observation status patients in the Observation Unit in order to bill appropriately.

Methods: Mid-February 2017, PI project identified by Unit-Based Practice Council to improve incomplete documentation and resulting lost charges. Mid-February through March 2017, interventions discussed and implemented: handoff report document modified to include designated lines for IV end time documentation; RN’s were encouraged to communicate pending IV solution end times every shift; education/reminders were provided in daily huddles by resource RN’s; RN’s were instructed to discontinue IV medication in the electronic health record before transfer, surgery, or at discharge; Net Page (Text) by Unit Administrative Partner (secretary) to remind nurses every 4 hours to document IV site & bag end time; and IV Pump set to alert nurses at the end of infusions.

Findings: IV site documentation compliance audits improved from 52.4% in the pre-intervention quarter (Oct-Dec 2016) to 71.7% in the immediate post-intervention quarter (Apr-Jun 2017); with improvements to 100% in each of the two subsequent quarters (Jul-Sep 2017 and Oct-Dec 2017). IV fluid/antibiotic end time documentation compliance audits improved from 14.3% in the pre-intervention quarter (Oct-Dec 2016) to 54.8% in the immediate post-intervention quarter (Apr-Jun 2017); with improvements to 93.3% in the Jul-Sep 2017 quarter and 100% in the Oct-Dec 2017 quarter.

Discussion: In order to bill appropriately for care related to IV fluid/antibiotic administration in the Observation status patient, IV site documentation and IV fluid/antibiotic start and end times must be documented. If any of these elements are missing, there is an inability to bill appropriately, resulting in lost charges and lost revenue. Through targeted staff education and interventions aimed at hardwiring the process to document appropriately, the Observation unit has been able to sustain improvements in the compliance of documentation of IV site and IV fluid/antibiotic end times. This has resulted in the ability to bill appropriately.

Implications for Practice: Appropriate documentation plays a vital role in the healthcare economy. Billing and reimbursement for services rendered are dependent upon accurate documentation. Excellence in nursing documentation will continue to help optimize organizational performance and promote a culture of safety for patients.

Publication Date


Presented At:

2018 West Kendall Baptist Hospital Scholarly Showcase

Content Type


Open Access

Available to all.