Health Information Management

Tip: Avoid injection and infusion pitfalls

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Infusions, injections, and vaccine administration continue to represent a compliance risk from overcharges and a lost charge risk.

The documentation necessary to support these charges is extensive and includes:

Start and stop times
Clearly labeled sites (e.g., “A, B, C,” or “1, 2, 3”)
Clearly labeled piggyback (IVPB) administration according to site, start and stop times, and medication included within the bag
Consistently stated facility IVPB nomenclature
Consistently stated push-drug administration nomenclature for your facility (e.g., if your facility uses “IV push,” you should not say “IVP”)

However, remember that having too many requirements can make it difficult for nursing staff members to comply.

This tip was adapted from the article “Solve the twin problems of ED revenue loss and compliance risk” from the May issue of Briefings on APCs.

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