Improving Nursing Documentation and Decreasing Revenue


Accurate and timely medical record documentation facilitates diagnosis and treatment, communicates pertinent information to other caregivers to ensure patient safety, and sup-ports optimal care delivery and patient outcomes. In addition, insufficient or inaccurate medical record documentation also increases the risk of medical errors and legal liability. Medical record documentation validates that appropriate treatment was carried out as or-dered and protects the professionals’ licensing credentials.

Emergency Department Charge and Document Nurses (CDRNs) conducted a medical rec-ords review from May 2015 to February 2017 which revealed documentation discrepan-cies on an average of seven out of 25 occurrences per month resulting in an approximate loss of $3,086 per month.

The purpose of this initiative was to increase the accuracy of documentation related to the casting and strapping procedures performed by qualified staff members in the Emergency Department (ED) as well as to decrease continued revenue loss for the Homestead Hospi-tal ED. The post-intervention period from March 2017 to August 2017 revealed a decline in inaccurate/insufficient documentation to an average of two out of 24 occurrences per month. In regards to revenue, the monthly loss had also decreased from approximately $3,086 to $1,096. Nursing documentation using CMS guidelines promotes patient safety, personal and legal accountability, protection of individual credentials/licensure and also optimizes revenue collected for the ED services rendered. The new education approach initiated by the CDRNs has demonstrated positive results by decreasing documentation discrepancies, and will continue to be applied during shift huddles, staff meetings, and during the new ED onboarding/looping process.

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Presented At:

13th Annual BHSF Research Conference

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