Hello All, I was wondering if your physicians were using the attestation statement instead of documenting the specific focused exam components. If so, how is that going? How did you implement this?
We had a miss this month: even though the physician documented in his note the specific amount of fluid that was given, followed with "after these interventions the patient was reassessed", we missed because the attestation did not have a specific time included. The time the note was opened/started was used. This was an ED note, started at the beginning of the pt's visit, so that was prior to fluids being given. It is frustrating to see that the correct care is being given, yet we are missing on documentation technicalities. Does anyone have suggestions? Thanks, Molly Molly Duane RN, BSN, CCRN Sepsis Program Coordinator Detroit Receiving Hospital Harper-Hutzel Hospital Mobile: 248-709-6218 DRH: 313-966-8087 HUH: 313-745-4340 Email: [email protected]<mailto:[email protected]> This message (including any attachments) is confidential and intended solely for the use of the individual or entity to whom it is addressed, and is protected by law. If you are not the intended recipient, please delete the message (including any attachments) and notify the originator that you received the message in error. Any disclosure, copying, or distribution of this message, or the taking of any action based on it, is strictly prohibited. Any views expressed in this message are those of the individual sender, except where the sender specifies and with authority, states them to be the views of Tenet Healthcare Corporation.
_______________________________________________ Sepsisgroups mailing list [email protected] http://lists.sepsisgroups.org/listinfo.cgi/sepsisgroups-sepsisgroups.org
