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CMW Tip of the Week: Standardize physician level of care orders

Case Management Weekly, January 7, 2009

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This week’s tip is provided by Deborah K. Hale, CCS.

When it comes to discerning level of care orders, free-hand orders are not always consistent from one physician to another, making it difficult to determine the physician’s intention.

An attempt to use standardized order sets to promote clarity of the physician’s order may be problematic if the format is poorly designed or if the level of care description is unique to your hospital. Orders such as “admit to medical short stay” (an internal description representing observation status for medical patients) would not likely be recognized as an appropriate observation order by an outside auditor.

For best results, checkboxes allowing the physician to choose the intended level of care will improve the level of care order accuracy if they are easily visualized and the opportunity to select the level of care is large enough to identify the physician’s selection. Wording should be consistent with Medicare/Medicaid regulatory guidelines and admission screening criteria sets:

• Admit as inpatient
• Admit to observation status
• Outpatient status (outpatient surgery, outpatient blood transfusion, etc.)

Computerized order entry should be designed to require the physician to select the level of care before proceeding with any other orders. To avoid any confusion, the level of care choices should reflect CMS required terminology described above.

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

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