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.