Health Information Management

Capturing start and stop times for infusions

APCs Insider, February 1, 2013

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During Wednesday's audio conference, Injections and Infusions: Review of Drug Administration Coding, Billing, and Charging for Hospitals, our speakers Jugna Shah, MPH, and Valerie Rinkle, MPA, asked the audience which drug administration documentation requirement posed the most challenge. A whopping 78% of the audience answered "lack of nursing documentation of injection/infusion start and stop times."

That took us all a little by surprise. Maybe it shouldn’t have. After all, CMS does not specifically require documentation of start and stop times. It does strongly hint that those times should be documented. Otherwise, how can you justify the number of minutes (or hours) an infusion ran?
You should have a physician order documenting the:
  • Drug
  • Dosage
  • Administration route
  •  Rate at which the drug is given
The nursing documentation should include, among other things:
  • Location of the injection/IV site
  • Patient vital signs at initiation of the infusion
  • Start time of each infusion
  •  Rate of each infusion
  • Time of each patient interaction during monitoring
  •  Stop time of each infusion
That last one seems to be the problem. Nurses are generally good at documenting the start time, but not so good at documenting the stop time. And that leads to a coding risk. Without a stop time, coders can’t really code the infusion and may end up reporting an injection instead. An injection is defined, in part, as an infusion that last less than 15 minutes.
Take a look at your own records for infusions and consider these questions.
  • How often are nurses documenting the actual stop time (and not a guess based on flow rate and dose)?
  •  Are certain nurses better or worse at documenting stop times? If some nurses always document stop times, ask them for some suggestions on how to improve documentation across the facility. If certain nurses do a very poor job of documenting stop times, work with them individually.
  • Are external factors affecting documentation of stop times? Are nurses being called away unexpectedly? Do you have enough nursing coverage? Is the problem caused by a shift change—one nurse starts the infusion and turns the patient over to another nurse before the infusion ends?
Capturing stop times isn’t always easy, but not doing it can cause bigger problems down the line when you get audited.

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