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What should critical care documentation include?

by Chase Collins

What should critical care documentation include?

Critical care documentation should always include:

  • The organ system(s) at risk.
  • Which diagnostic and/or therapeutic interventions were performed, including rationale.
  • Critical findings of laboratory tests, imaging, ECG, etc., and their significance.
  • Course of treatment (plan of care)

What are the 7 legal requirements of progress notes?

Be clear, legible, concise, contemporaneous, progressive and accurate.

  • Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
  • Meet all necessary medico-legal requirements for documentation.

    • What are the standards designing for ICU?

    Ward-type ICUs should allow at least 225 square feet of clear floor area per bed. ICUs with individual patient modules should allow at least 250 square feet per room (assuming one patient per room), and provide a minimum width of 15 feet, excluding ancillary spaces (anteroom, toilet, storage).

    How many times can you bill 99291?

    Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician. CPT code 99291 should be used once per calendar date per patient by the same physician or physician group of the same specialty.

    What is critical care first hour?

    The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date.

    What are the two basic rules of documentation?

    GUIDELINES FOR PROGRESS NOTES Basic rules of documentation: 1. Date and time all notes. 2.

    What is documentation and reporting?

     DOCUMENTATION serves as a permanent record of client information and care.  REPORTING takes place when two or more people share information about client care, either face to face or by telephone. 4.

    What is the highest level of ICU?

    A level 1 ICU is capable of providing oxygen, noninvasive monitoring, and more intensive nursing care than on a ward, whereas a level 2 ICU can provide invasive monitoring and basic life support for a short period.

    What are the five C’s in medical record documentation?

    Client’s Words, Clarity, Completeness, Conciseness, Chronological Order and Confidentiality.

    How can you complete and maintain documentation?

    Maintaining Documentation in an Aged Care Environment – It Doesn’t Need to be Hard

    1. Identify what documents are needed.
    2. Determine who is responsible for obtaining information.
    3. Ensure that all documentation complies.
    4. Establish a document control process.
    5. Establish review timelines.