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ABSTRACT: Objective
The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative.Methods
We collected POCUS documentation and billing data from the EMR. Interventions included: (1) staff education and feedback, (2) standardization of documentation and billing, and (3) changes to the EMR to support standardization. We used P charts to analyze our outcome measures between January 2017 and June 2018.Results
Six hundred medical records of billed POCUS examinations were included. Complete POCUS documentation rate rose from 62% to 91%, and correct CPT code selection for billing increased from 92% to 95% after our interventions.Conclusions
The creation of a standardized documentation template incorporated into the EMR improved complete documentation compliance.
SUBMITTER: Ng C
PROVIDER: S-EPMC7375490 | biostudies-literature | 2020 Jul-Aug
REPOSITORIES: biostudies-literature
Ng Carrie C Payne Asha S AS Patel Amit K AK Thomas-Mohtat Rosemary R Maxwell Angela A Abo Alyssa A
Pediatric quality & safety 20200721 4
<h4>Objective</h4>The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative.<h4>Methods</h4>We collected POCUS documentation and billing data from the EMR. Interventions included: (1) staff e ...[more]