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Q&A: Documentation for admitting a newly discharged patient

HIM Connection, January 31, 2012

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Q: A patient is discharged from our hospital so he can be transferred by helicopter to another facility. While on the helicopter pad he codes, and we must readmit him 29 minutes later. This means he doesn’t actually leave the hospital property after the discharge. Should we separate documentation for this case into two visits, or should we simply update the history and physical with a progress note? Should nursing documentation reflect readmission?

A. A patient is readmitted for a new event (i.e., the code on the helicopter pad). However, I suggest that you work with your case management department determine whether it should be combined with the original admission. Payer requirements are an important element in making this determination.

Your question does not include any of the details regarding the original admission. However, if the code event and the initial admission are related, you may need to combine the visits. Providers should document all events that prompted the second admission. Documentation also should include an interim readmission note from the physician and nursing staff.

Editor’s note: Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children’s Hospital at Sanford in Palo Alto, CA,answered this question, which first appeared in the January issue of Briefings on Coding Compliance Strategies.

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