IV start and stop documentation for reimbursement

Specialties Med-Surg

Published

Specializes in Med - Surg.

I am a med-surg RN with an IV documentation problem. Here is my delimma... In our hospital, we use EPIC EMR. When we scan to hang any IV fluid/med bag, we have to leave the patient room and get the patient chart from a little closet just outside the patient room and write in the fluid/med hung along with start date and time and end date and time. My nursing manager and director have explained to me that by keeping a start/stop list of these IV fluids, that guarantees our reimbursement and has saved us a lot of money. If we fail to document start and stop times, we lose money.

I have so much trouble remembering to stop, go to patient chart and write this down. I know it does not sound to difficult, but when I leave the patient room and cross that threshold, I'm off running to another task or patient need. Some nurses have started removing each patient's flow sheet from the chart and carrying them around on their clipboards to remember, but I don't carry a clipboard and find that to be just one more cumbersome problem, and I fear of misplacing the entire sheet.

I am asking what does your hospital do to keep up with start/stop times for IV fluids? There must be an electronic way or at least a more efficient way. Any feedback will be so very much appreciated:o

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Specializes in ED, ICU, now eductor.

We use Meditech for charting. When we give any IV med, the computer asks us to reassess it in half an hour. This works great on IV piggybacks for charting your stop time. For our normal IV fluids, the reassess icon stays on your screen until you click on it when the IV fluid bag is complete.

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Specializes in learning on an ortho floor.

Our hospital is not up electronically with medications yet. I must grab the MAR, go to the pixis/med.room, retrieve the medication (after reading the scribble), go to the pt's. room, identify the pt., medicate the pt., document in the MAR, put the MAR back...then go to the computer and document on a pain flowsheet about the pt's. pain and the intervention....then within 90 minutes....go back and re-assess....then go back to pain flowsheet and document the outcome.....;).....:0....;) Please....honestly....is it really that hard for you?

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Specializes in learning on an ortho floor.

Can't you just put in the stop time....like how long are you running that antibiotic..1hr...start=1800...stop=1900....Or maybe I am not understanding you...you have to program the pump right?

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Specializes in Med - Surg.

Yes, I totally understand paper charting on MAR and have had to do it that way before. I guess that is what I'm more used to actually and perhaps that's why this is a little difficult for me to embrace. Again, I know it sounds hard to believe, but when doing ALL meds on paper chart I had to go to the chart for everything, so even though time consuming and a pain also, I was in the chart a lot and everything got documented the same way. I never missed anything. This new way is disjointed. Everything is in computer except the stop time option. The chart is an afterthought and for that reason gets missed. If I were in the chart more - no problem. Or if stop time were in our computer MAR - no problem. At first I thought it was just me and being new, but soon discovered seasoned nurses and everyone else having same problem. No, it's not hard, just looking for a better way to stay consistent and not lose money.

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Specializes in Med - Surg.

We do program the Iv pump for run time. I don't think I have the option on our pumps to go back and look at a history of sorts. We use Alaris pumps. On a good day and I am able to go back to chart and document on the paper IV flow sheet. I'll write in start and stop time at the first because I know there is no way I'm gonna get back in that room in thirty minutes exactly or one hour exactly. If the flow was interrupted then I will correct the flow sheet times if necessary. If anyone knows how to see a history on Alaris pumps, please let me know how. I can also view a history on our electronic MAR of what I hung and I know for how long, but it's the transferring it to the paper flow sheet that's the problem. If I'm less busy - no big deal, really. Usually I'm so crazy busy with more urgent matters, that the paper flow sheet is not my priority. I guess ultimately I really just need to know if anyone else uses EPIC and knows how to put in a stop time on that program's electronic MAR so that the paper charting can come to an end.

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