Friday, March 21, 2008 at 9:42:03 AM

In order to insure proper coding for core measures, please remember the following:

o Use the word “clip” not shave when describing surgical activity.
o Document contraindications when not utilizing a core measure treatment, i.e. ACE or ARB for LVSD.
o Provide supporting documentation of infection when not discontinuing antibiotics 24 hours post-op.
o Dictated discharge summary medication list must match the discharge orders and instruction sheet given to patient at discharge.

Small changes in documentation can make a big difference in how UHS Hospitals is viewed in national reporting of statistics by Centers for Medicare & Medicaid and others. Your attention to these items is appreciated.

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