SurgiNet Charge Review

Transcription

SurgiNet
Charge Review
Student Manual
July 2012
Table of Contents
Table of Contents
INFORMATION SECURITY AND CONFIDENTIALITY .................................................................................... 4
OVERVIEW ............................................................................................................................................... 5
COURSE AUDIENCE...........................................................................................................................................5
PREREQUISITES ................................................................................................................................................5
USING THIS TRAINING MANUAL ..........................................................................................................................5
TERMINOLOGY ................................................................................................................................................6
SIGNING ON ............................................................................................................................................. 7
CASE SELECTION SCREEN ...................................................................................................................................8
PRINTING REPORTS FOR CHARGE REVIEW ............................................................................................... 9
INFOCLIQUE - SURGERY SCHEDULE: ...................................................................................................................11
SURGINET CASE SELECTION SCREEN - IMPLANT LOG REPORT:.................................................................................12
BIRTH LOG:...................................................................................................................................................13
ACCESSING CHARGE REVIEW .................................................................................................................. 14
RUNNING THE CHARGE JOB..............................................................................................................................15
REMOVING RECORD FROM CHARGE REVIEW REPORT ............................................................................................16
COMPLETING CHARGE REVIEW .........................................................................................................................17
COMPLETING CHARGE REVIEW - MATERNITY ......................................................................................................21
VIEWING PERIOPERATIVE DOCUMENTATION ........................................................................................ 23
VIEWING PACU/RECOVERY DOCUMENTATION ...................................................................................... 24
FREE-TEXT CHARGES .............................................................................................................................. 25
MODIFY PICK LIST................................................................................................................................... 26
ADD MISSING SUPPLIES OR CORRECT SUPPLIES ....................................................................................................26
APPENDIX A – CUSTOMIZING COLUMNS IN CHARGE VIEWER ................................................................ 30
APPENDIX B – FILTERING SELECTIONS ON CASE SELECTION SCREEN....................................................... 31
APPENDIX C – CHARGE PROCESS FLAG LEGEND...................................................................................... 32
APPENDIX F – TERMINOLOGY ................................................................................................................ 34
APPENDIX G – ADMIT TYPES .................................................................................................................. 36
APPENDIX H – CHARGE INFORMATION .................................................................................................. 37
APPENDIX I – PER CHARGE SUMMARY REPORT ..................................................................................... 39
LOGGING OUT ........................................................................................................................................ 40
3
(Rev. 5/4/2012)
INFORMATION SECURITY AND CONFIDENTIALITY
When dealing with computerized health care records, specific confidentiality and security issues must be
followed to protect the patient. There are increasing HIPAA and Joint Commission regulations that dictate
how these records are handled.
4
•
When signing on to SurgiNet use your own User Name and Password, do not share.
•
SurgiNet keeps an audit trail, or record, of who enters each chart and when. The application
records who signed into the chart and who documented each piece of information in the
chart.
•
Do not leave the computer while still signed on.
•
Do not access any information that does not apply to your current job and caseload.
OVERVIEW
COURSE AUDIENCE
The target audience for this course will consist of staff (formerly known as Poders) responsible for
verifying charges on cases and making corrections when and if necessary.
Upon completion of this training program, participants will be able to:
Print Scheduling and Implant Reports for charge review
Review Case Charges in SurgiNet
Run Charge Job
Process Free-Text items
Enter missing charges
Follow-up on Held charges
PREREQUISITES
All participants are expected to be competent in the following areas:
Introduction to Windows
USING THIS TRAINING MANUAL
This training manual was designed to help new users learn how to effectively use SurgiNet for Charge
Review.
Pictures of various screens have been included to familiarize you with the process.
NOTE:
Please note that the charges listed in this document are listed as examples only
and are not a complete or comprehensive list of charges.
It is the responsibility of the person reviewing the charges to ensure that all
appropriate charges appear on the chart.
If there are charges that are incorrect or missing, you are required to contact
the RN who completed the documentation, along with the RN/Unit Manager to
get them added/corrected.
Notifying the RN/Unit Manager also increases awareness of any training
deficiencies that need to be addressed.
5
(Rev. 7/27/2012)
TERMINOLOGY
The following terms will be used frequently referenced in this manual:
Case Selection Screen: This is the initial screen displayed when logging on to SurgiNet. All cases
scheduled on the Scheduling Appointment Book display. Selections can be made for location and
date ranges.
Charge Review: A report that allows viewing of documentation that has been held. Displays user
and reason why documentation is on the report.
Run Charge Job: Manually running a charge job allows a “real-time” view of charges from SurgiNet
documentation to the Charge Viewer.
Perioperative Documentation: Electronic documentation completed by nursing. The documentation
drives charges.
Clinical Folders: The location within a patient’s chart where Perioperative Documentation can be
viewed.
Picklist: A list of items that may be used in a case. The picklist is found within the perioperative
documentation.
Charge Status:

Interfaced – these are charges that have been processed and interfaced to Eclipsys.

Pending – these are charges that have been entered and are awaiting the nightly interface
to Eclipsys.

Manual – these are charges that require manual intervention before they can be interfaced
to Eclipsys (such as free-text items).
Free-Text Items – Items that did not have a CDM (Charge Code) available at the point of
documentation. These items are still entered by nursing but will have zeros in the CDM field.
PCM – PowerChart Maternity.
PCM Tracking Shell – Provides all L&D staff with a single point of access to all pertinent patient
information.
Birth Log – Provides a record of all patients who gave birth.
6
SIGNING ON
To log onto Power Chart/SurgiNet:
1.
Click the blue Citrix icon on the application bar on the bottom right of your screen.
2.
Click Applications and then click SurgiNet Prod.
3.
Enter your User ID and Password.
4.
Click the OK button.
7
(Rev. 7/27/2012)
CASE SELECTION SCREEN
The case selection screen displays upon logon to SurgiNet. Reports are accessed from this screen.
Patients displayed on the Case Selection screen were scheduled on the Scheduling
Appointment Book.
Cases displayed in red were cancelled.
NOTE: See Appendix for how to change Location and Date Ranges.
8
PRINTING REPORTS FOR CHARGE REVIEW
To begin charge review, you will need to print the Scheduling Report and the Implant Log for the areas
you are responsible for completing charge review in. The reports are how you know who to complete the
charge review process for.
To run daily reports, you need to be on the Case Selection screen. This report shows opened and
unfinalized documentation. Nursing needs to address these records.
1.
Click the Report Manager icon from the toolbar.
A message displays letting you know the Report Manager is loading.
2.
Click the Location button on the toolbar.
The Location Selection dialog box displays.
3.
Select the appropriate location.
4.
9
(Rev. 7/27/2012)
5.
Select the Report Type Non-Finalized Documents – All Scheduled Cases.
6.
Enter the date range in the From and To fields.
7.
Select the printer if it is not defaulted.
8.
Click the Document Types tab.
9.
Select the appropriate record by clicking the checkbox.
10. Click the Preview button to view the report before printing it.
11. Click the Print button.
10
INFOCLIQUE - SURGERY SCHEDULE:
1.
Launch the Internet Browser.
2.
Select the Log-In tab from the Kaleidascope homepage.
3.
Log in to Kaleidascope using your Network User ID and Password.
4.
Select the Applications tab of Kaleidascope.
5.
Select the InfoClique application from the Secured Applications.
6.
Scroll down to the SurgiNet Schedule section.
7.
Select the appropriate site and roomset.
8.
Enter the date for the report.
This is typically the previous day’s schedule.
9.
Click the Search button.
10. Click File and Print from the task bar.
11
(Rev. 7/27/2012)
SURGINET CASE SELECTION SCREEN - IMPLANT LOG REPORT:
1.
Click the Explorer Menu button on the toolbar.
2.
Click KH Implant/Explant Log from the folder.
3.
Click the location you need the report for on the right side of the screen.
4.
Enter a Start and End date in the fields.
5.
Click Execute.
The report displays.
6.
Click Task and select Print to print the report.
The first time the Implant Log is printed, double-click the Main Menu folder and open the
SurgiNet folder.
Open the correct site and select the correct location.
Information on the Implant/Explant log comes from Clinical Documentation, not the picklist.
Information from the picklist displays in the Charge Viewer.
12
BIRTH LOG:
The previous day’s Birth Log will need to be printed in order to complete the Maternity Charge Review.
1.
Click the PCM (PowerChart Maternity) Tracking Shell.
2.
Click the Discern Reports icon.
3.
Select OB Reports as the report type.
4.
Select the Birth Log Book Extractable report.
5.
6.
Enter the start and end date.
7.
Select the Organization (MFS or WCHOB)
8.
Run the Report.
The patients listed on the report are the patients that you need to review charges for.
13
(Rev. 7/27/2012)
ACCESSING CHARGE REVIEW
The Charge Review list of cases must be worked EVERY day. If cases remain on hold, auto-replenishment
will be held up. Also, the department will not receive revenue until the case documentation has been
finalized by nursing.
From the Case Selection screen:
1.
Click the Charge Review button on the toolbar. (The charge review icon with the eyeglasses)
The SurgiNet Charge Review screen displays. There is no date range on this report. All
documentation that is held will display here until it has been corrected.
The charge review screen displays all pending documentation completed for that day, or any cases that
require intervention by a user.
Black Text – indicates charges that are complete and waiting for the nightly operations job
to run.
Blue Text – indicates charges that require manual intervention. The Submitted column
indicates the user who completed the documentation. The Comments column helps the
user to determine the type of intervention needed.
14
Red Text – indicates “Pick List” items that were not charged.
To view patient name: Rightclick the Case # and select
Properties.
The patient name displays.
RUNNING THE CHARGE JOB
To complete the charge review process, you need to run the charge job to show the most current
information in the system. This process moves all of the cases in Black text (finalized cases) to the Charge
Viewer. Any cases remaining in Blue or Red font need to be looked at and followed up on.
1.
On the Charge Review screen, click Task from the toolbar.
2.
Select Run Charge Job.
15
(Rev. 7/27/2012)
The Charge Job Options window displays.
Select the Document Type of the area you have
charge review responsibilities for.
3.
Click the Run button to start the processing job. Never click the box next to Logging.
4.
Click the Refresh button.
REMOVING RECORD FROM CHARGE REVIEW REPORT
When a case remains in Blue on the Charge Review list because it was ‘Cancelled in Pre-Op’, you will need
to delete the case from the Charge Review list. There are other reasons as well such as: Documented in
Error, Other-Terminated, Not Applicable to Case, Case Cancelled in OR, etc.
1.
Select the lines within the case record that need to be deleted. (*To select multiple lines, hold
the Shift key and click the lines).
2.
Right-click the highlighted lines and select Delete.
3.
Click the Save button on the toolbar.
4.
Click Task and select Run the Charge Job from the shortcut menu.
5.
Click the Refresh button.
The record will be deleted from the Charge Review list.
16
COMPLETING CHARGE REVIEW
To review charges for a specific case, you have to open the patient’s chart in Power Chart. If a patient has
charges on the Implant Log, verify that these charges are listed on the Charge Viewer.
1.
On the Case Selection screen, enter the previous day’s work in the From Date and To Date fields.
(Or enter the date of the charges you are reviewing)
Verify that the correct Location is selected.
2.
Click the Retrieve button.
3.
Double-click the patient name you need to review charges on.
See Appendix B for how to filter selections (dates, locations) on the Case Selection screen.
The patient’s chart opens to the Patient Information section.
17
(Rev. 7/27/2012)
4.
Click on the Charges icon on the toolbar (the one with the glasses).
5. Assign a relationship.
The relationship is assigned the first time you open the patient’s chart.
6. Click the OK button.
The CS Charge Viewer screen displays.
7.
18
Click on the charge line with the Case number showing in the Accession column. The charges
expand and you need to review all charges on the account. See below:
See Appendix A for how to customize columns on the CS Charge Viewer.
8.
View the Status column for charges listed as Manual and Interfaced.
Interfaced – You cannot change or modify charges in an interfaced status.
Manual – Charges in a manual status require review for free text items that are missing
CDM’s.
19
(Rev. 7/27/2012)
o
Never leave charges in a Manual status.
o
Charges will display in a Manual status for any of the following reasons:
o
Free-Text charges that have 0’s listed for the CDM.
The Accession column on the Charge Viewer equals the Surgical Case Number for the
patient.
Blue Charge lines for any PREOP Record, PHASE I or PHASE II Records need to be opened by
clicking on them.
o
Pre Op charges display on the Charge Viewer once Pre Op Documentation has been
completed and finalized by Nursing.
o
Phase I charges display acuity levels once the documentation has been completed and
finalized by Nursing.
o
Phase II charges display on the Charge Viewer once Post Op Documentation has been
completed and finalized by Nursing.
If there should be PACU or Recovery charges for a patient and you do not see them, you
must open the Charge Review report in SurgiNet. (See section in this manual for Accessing
Charge Review)
If there is not a Pre Op/Post Op charge and there should be, you will need to notify the
Nurse who performed the Pre/Post Op documentation to have this corrected. If unable to
notify the nurse, notify the manager. This should be done in a timely manner so staff will
remember the case. (See “Viewing Pre/Post Op Documentation section to determine who
completed the documentation)
Validate the type of anesthesia used for the case to assist in determining what charges
should exist.
Validate the date on the charges matches the date of service.
Validate that a PreOp Record shows a charge for AMB SURG FEE PRE and a PACU Record
shows a charge for AMB SURG FEE POST.
20
3.
If the date on the documentation is incorrect, notify the Nurse who completed the
documentation as well as the Nurse Manager. They will have to un-finalize the documentation,
correct the date and finalize the documentation again.
4.
Open the Charge Review report and Run the Charge Job for the record type that had the
incorrect date of service.
*Free Text items are corrected in charge review by adding the correct charge code and
description. See instructions in this manual for Free-Text Charges.
It is not necessary to go into the picklist to make these corrections.
9.
Click the charge line to expand.
10. Review the charges - validate Pre Op, Recovery and Post Op charges.
COMPLETING CHARGE REVIEW - MATERNITY
This section is for staff responsible for the completion of charge review for maternity patients at Millard
Fillmore Suburban Hospital or at Women’s and Children’s Hospital.
Triage Patients NOT Admitted:
Non-Stress Tests remain on paper and will be charged via Batch Charge Entry.
The current charge auditing process will continue.
Vaginal Deliveries:
1.
Print the previous day’s Birth Log from PowerChart.
2.
Open the patient’s chart and click on the Charge Viewer icon.
3.
Ensure the following charges are present:
Delivery Charge for single or multiple birth
Reasonable quantities for chargeable items (<5)
Other items/procedures have charges
4.
If everything appears in order the Charge Review Process is complete.
Missing charges/Questions
5.
Locate the staff member who documented the patient chart and have them correct the
documentation.
We recommend that the Charge Nurse /Unit Manager also be advised. In cases where the
documenting nurse is unavailable the Charge Nurse /Unit Manager can correct the
documentation.
In addition, the Charge Nurse/Unit Manager can determine if this is a training point that
needs to be addressed with the nursing staff.
Cesarean Sections
1.
Print the previous day’s Birth Log from PowerChart.
2.
Open the Patient’s chart and click on the Charge Viewer icon.
3.
Ensure the following charges are present:
$Antiembolism/Sequential Stockings
21
(Rev. 7/27/2012)
Foley Catheter
C-Section Pack
Anesthesia Type
Operating Room Time
Staff in Room Time
Recovery Time
4.
If everything appears in order the Charge Review Process is complete.
Missing charges/Questions
5.
Locate the staff member who documented the patient chart and have them correct the
documentation.
We recommend that the Charge Nurse /Unit Manager also be advised. In cases where the
documenting nurse is unavailable the Charge Nurse /Unit Manager can correct the
documentation.
In addition, the Charge Nurse/Unit Manager can determine if this is a training point that
needs to be addressed with the nursing staff.
22
VIEWING PERIOPERATIVE DOCUMENTATION
The following steps show how to view Perioperative Documentation to see who was in the room for a
case or to see if the documentation exists.
1.
Double-click the patient’s name on the Case Selection screen to open their chart.
2.
Click Clinical Folders component from the Menu.
3.
Search by Date on this screen.
To change the date range to allow the documentation to display, right-click the blue date
banner and click change search criteria.
4.
Double-click the folder in the panel that you want to open.
5.
Double-click the OR Record document to view it.
23
(Rev. 7/27/2012)
VIEWING PACU/RECOVERY DOCUMENTATION
The following steps show how to view Pre/PACU Recovery Documentation to see who performed the
documentation.
1.
Double-click the patient’s name on the Case Selection screen.
2.
Click Clinical Folders in the Menu on the left of the patient’s chart.
3.
Search by Date. To change the date range to allow the documentation to display, right-click the
blue date banner and click change search criteria.
4.
Enter a From and To date and click the OK button.
5.
Double-click the folder in the panel that you want to open.
6.
Double-click the correct encounter Record (Pre Op/Phase I/Phase II) to view the documentation.
The document will show the name of the user who performed the Pre/Phase I/Phase II
Documentation.
24
FREE-TEXT CHARGES
1.
Highlight the charge line on the Charge Viewer screen that is missing the CDM/Lawson number.
2.
Right-click the charge line and select Release Charge.
The Suspended Charge Release window displays.
3.
Double-click on the Red charge line.
4.
Enter the CDM in the Bill Code column.
If necessary, type the correct description in the Description column.
5.
Click OK and then click the Release ALL button.
Be sure to not click the Absorb All button.
Note: Missing CDM numbers can be obtained in Lawson Item Search or from your Materials
Management contact.
The Charge Viewer displays.
6.
Click the Refresh button on the toolbar.
The manual charges now have a status of Pending or Absorbed and will interface when the
nightly Ops job runs.
Note: You will not be crediting any charges in the Charge Viewer. All charges or credits must be
completed within the Picklist in the Perioperative record.
25
(Rev. 7/27/2012)
MODIFY PICK LIST
ADD MISSING SUPPLIES OR CORRECT SUPPLIES
The following steps outline how to Modify the patient’s Picklist to add missing supplies or to enter a
correct supply and remove an incorrect supply.
1.
From the Case Selection screen, double-click the patient’s name to open their chart.
2.
Click Perioperative Doc component from the Menu.
Red flag - unfinalize
3.
Click the red flag icon to un-finalize the document.
Unfinalize Document window displays.
4.
Select Modify Pick List.
5.
The Perioperative Document opens to the Documentation Tab.
6.
26
Click the Pick List tab.
Remove an Item:
7.
Locate the item and change the Used QTY to 0 (zero).
Add an Item:
8.
Click in the search field.
9.
Type the new code.
If the new item is not in the data-base, type in the description and the CDM number.
10. Click ADD.
11. A Resolve Multiple window may display. If it does, you must choose the exact match.
Use the scroll bar or arrows to review the choices.
12. Click the OK button.
27
(Rev. 7/27/2012)
The item now shows at the top of the Pick List.
13. Type the Used QTY and press ENTER on the keyboard.
Quantity Exhausted message displays.
14. Click the Yes button.
The Fill QTY will automatically be updated.
15. Click the Save icon on the top of the Perioperative Document.
This is the only way your changes will be saved.
Click the Save icon
to save your work.
16. Click the Documentation tab.
17. Click the green flag icon to finalize the documentation.
28
18. In the Document Verified message, select Yes.
19. In the Print Document message, select No.
Note: To see the corrections, you need to Run the Charge Job (see section in manual for steps to Run
the Charge Job). After Running the Charge Job, you will be able to see the charges on the Charge
Viewer in the patient’s chart.
29
(Rev. 7/27/2012)
APPENDIX A – CUSTOMIZING COLUMNS IN CHARGE
VIEWER
To customize your view in the Charge Viewer:
1.
Click the Task menu.
2.
Click Customize Columns.
The Customize Columns window displays.
3. Selected columns
will display here.
1. Select a column.
2. Click Add.
3.
You can change the
order of the columns
by selecting an item,
then clicking the up or
down button on the
right.
Click to select a column and click the Add button.
Columns will appear in the order in which you add them.
4.
Repeat this process until you have all the columns selected that you would like to view.
Be sure Accession Number is selected as one of your columns.
30
5.
Click the OK button to return to the Charge Viewer.
6.
Click the Refresh button
on the Charge Viewer toolbar to activate the customized view.
APPENDIX B – FILTERING SELECTIONS ON CASE
SELECTION SCREEN
The dates and locations on the Case Selection screen can be filtered as needed.
1.
Change the From Date and To Date as needed.
2.
Click the Location button (above the To Date field) to change the Location.
The location can also be changed from within the Charge Review by clicking the same
button.
3.
Select the location for the charges you are working on and click the OK button.
31
(Rev. 7/27/2012)
APPENDIX C – CHARGE PROCESS FLAG LEGEND
32
Anest
hesia
Type
No anesthesia or local
Minor procedures
Urology - procedures
Ex: Excision of lesion
GI - colonoscopy, EDG, etc.
Case Selection screen: Locate correct patient using
DOB and FIN#. Complete Surginet "Check-in".
Update Case Tracking Board
Case Selection screen: Locate correct patient using DOB
and FIN#. Complete Surginet "Check-in".
Open patient's chart.
Click on Ad Hoc Icon; select & complete "Basic
Admission Information" form. This includes
height/weight/allergies
From TOC select and complete Medication List
From TOC select Perioperative Doc.
Open and complete Pre-op Record. Enter appropriate
admission time as noted in Case Tracking Board. (NO
PRE CHARGE WILL DROP FOR MODERATE
SEDATION CASES).
Open and complete Pre-op Record Anesthesia. Enter appropriate
admission time as noted in Case Tracking Board. (PRE CHARGE
WILL DROP).
From TOC select and complete Histories
Click on Ad Hoc Icon: select "Basic Admission
Information" and "Preprocedure Checklist" forms.
Complete "Basic Admission information" form. This
includes Ht, Wt, Allergies.
Complete "Preprocedure Checklist"
Click on Ad Hoc Icon: select "Basic Admission Information" and
"Preprocedure Checklist" forms.
Complete "Basic Admission information" form. This includes Ht, Wt,
Allergies.
Complete "Preprocedure Checklist"
From TOC select Periop Flowsheet
Select Quickview band
Document Vital Signs and Pain assessment in the
appropriate sections of the Quickview band.
Place an order for starting IV or Hep Trap in
PowerOrders, and document the IV/hep trap in Iview
Periop Lines and Devices band.
Any additional charges via pick list
Complete paperwork as needed (consent, universal
protocol, etc).
Document Vital Signs and Pain assessment in the appropriate
sections of the Quickview band.
UTILIZE PRESENT Minor Procedure Record. Case
Tracking Board updates based on intraop
documentation.
UTILIZE PRESENT GI Record or Urology Record
Document Vital Signs in Iview and Medications in
Surginet. Toggle between the two screens as you
administer Moderate Sedation.
**MODERATE SEDATION CHARGE WILL DROP based
on anesthesia type, case level and minutes
UTILIZE PRESENT GI Record or Urology Record
Document departure from MPA segment from present
intra-op doc.
Phase 2 Nurse selects patient from Case Selection Screen
and opens pt's chart.
PHASE 1 PACU ONLY: Phase 1 RN selects patient from Case
Selection screen and opens pt's chart.
Select and complete PACU Phase 2 Record. (Enter the
accurate admission time to Phase 2 PACU). (NO POST
CHARGE WILL DROP FOR MODERATE SEDATION
CASES).
Select and complete PACU Phase 1 Record. (Enter the accurate
admission time to Phase 1 PACU). (CHARGE WILL DROP BASED ON
PACU MINUTES AND ACUITY).
Click on the Perioperative Quickview Band. Document
in the PACU arrival section.
Select Events and Procedures band, select moderate
sedation section to document post procedure
assessments
Click in the Periop Systems Assessment Band document
Pain assessment and other appropriate assessments
(i.e. Gastrointestinal, Genitourinary).
Use Depart icon to access discharge instructions & patient
education.
Outpatients only: KH PM conversation to discharge
Select and complete the appropriate bands. (ex: Quickview, Systems
Assessment, Recovery Room).
Complete paperwork as needed (consent, universal
protocol, etc).
Manually updates CTB "Pt ready"
Intra
Use Depart icon to access discharge instructions &
patient education.
Charges via pick list
Case tracking board to discharge all patients.
Post
Anesthesia cases
Urology -procedures
GI - ERCP
or other proc under anesthesia
Case Selection screen: Locate correct patient using DOB and FIN#.
Complete Surginet "Check-in".
Pre
Moderate Sedation
Case tracking board to discharge patient
Complete paperwork as needed (consent, universal protocol, etc).
Urology Anesthesia cases: From TOC select Perioperative Doc. Select
and complete Holding record.
**ANESTHESIA CHARGE WILL DROP based on anesthesia type,
case level and minutes
Anesthesiologist will "sign out" patient using current paper anesthesia
record.
Complete PACU Phase 1 record in Surginet.
Phase 1 PACU ends. Inpatient returns to Nursing Unit. Outpatient
moves to Phase 2 PACU.
Phase 2 Nurse selects patient from Case Selection Screen and opens
pt's chart.
Select and complete PACU Phase 2 Record. (Enter the accurate
admission time to Phase 2 PACU). (Phase 2 PACU CHARGE FOR
NURSING CARE OF PT RECEIVING ANESTHESIA WILL DROP).
Select and complete the appropriate bands. (ex: Quickview, Systems
Assessment).
Use Depart icon to access discharge instructions & patient education.
Case tracking board to discharge patient
33
(Rev. 7/27/2012)
APPENDIX F – TERMINOLOGY
Birth Log
Provides a record of all patients who gave birth.
Bucket
A consolidation of charges used in a case (Ex: plates and screws in an ortho case).
Vendors will determine if the bucket is valid.
Case Number
All patients scheduled in SurgiNet will have a Case Number. The format for a
Case Number is: MFSOR-2011-123. It begins with the site, followed by the
specific location of the procedure, then the year it was booked and a unique
number for the case.
Case Number = Accession Number on the Charge Viewer.
Case Selection Screen
This is the initial screen displayed when logging on to SurgiNet. All cases
scheduled on the Scheduling Appointment Book display. Selections can be made
for location and date ranges.
Charge Job
Manually running a charge job allows a “real-time” view of charges from
SurgiNet documentation to the Charge Viewer.
Charge Viewer
A screen within a patient's chart that lists all charges for the patient's encounter.
The columns within Charge Viewer can be customized to allow users to select
specific information and the order of the information on the screen.
Charge Review
A report within SurgiNet listing cases and documentation types completed for
the cases. The report is processed nightly through an Ops Job. This report needs
to be manually run by the user performing the Charge Review Process prior to
beginning the Charge Review Process. The report must be run for each
document type the user is responsible for performing the Charge Review Process
for. Running the report manually provides the user with the most up-to-date
view of charges on the Charge Viewer screen. It also shows a user what
documents are held due to Nursing errors.
Clinical Folders
34
The location within a patient’s chart where Perioperative
Documentation can be viewed.
Free Text Items
Items that did not have a CDM (Charge Code) available at the point of
documentation. These items are still entered by nursing but will have
zeros in the CDM field.
Implant/Explant Log
A report within SurgiNet that contains records for Implants and/or
Explants user per case. Information on the Implant/Explant Log comes
from Clinical Documentation. It is possible for nursing to document an
Implant and forget to select/add the Implant to the pick list. If nursing
forgets to select/add the implant to the pick list, the Charge Viewer will
not display a charge for the Implant.
Interfaced
Charges that have been processed and interfaced to Eclipsys.
Manual
Charges that require manual intervention before they can be
interfaced to Eclipsys (such as free-text items).
Surgery Schedule
Report of scheduled surgeries run from Infoclique that detail the
Surgeries. This report should be run daily for the surgeries scheduled
the previous day.
PCM
PowerChart Maternity.
PCM Tracking Shell
Provides all L&D staff with a single point of access to all pertinent
patient information.
Pending
Charges that have been entered and are awaiting the nightly interface
to Eclipsys.
Perioperative Documentation
Electronic documentation completed by nursing. The documentation
drives charges.
Pick List
A list of items that may be used in a case. The pick list is found within
the Perioperative documentation.
35
(Rev. 7/27/2012)
APPENDIX G – ADMIT TYPES
ADMIT TYPE
AS
EXPECT TO SEE
Ambulatory Surgery (patient will arrive day of procedure and is expected to go home
the same day of the procedure
Preop Record should be on the Charge Viewer screen and include a Pre-op Charge
PACU 1 Record should be on the Charge Viewer screen and include an acuity level
charge
PACU II Record should be on the Charge Viewer screen and include a Post-op Charge
(if an AS patient gets admitted after surgery, there won't be a PACU II record with a
post-op charge)
SDA
Same Day Admit (Patient will arrive day of procedure and is expected to be admitted
after the procedure)
charge
There should not be a PACU II Record for a patient who is admitted after their surgery
ONR
Over Night Recovery Ambulatory Surgery (Patient will arrive day of procedure and has
the potential to stay for extended recovery)
charge
PACU II Record should be on the Charge Viewer screen and include a Post-op charge
IH
In-House Patient is already in-house when the procedure is scheduled
No Preop Record should be present
PACU 1 Record with acuity level should be on Charge Viewer (if patient went to ICU
post-op they won't have a PACU 1 record either)
OP
Out Patient Ambulatory Procedure (patient will arrive day of procedure and is
expected to go home the same day of the procedure, typically used for patients who
will not have General Anesthesia)
PDA
Prior Day Admit (Patient will be admitted the day before the surgery date)
Same as IH
36
APPENDIX H – CHARGE INFORMATION
The information provided on this document is meant as a guide. For comprehensive procedure
charge information, please utilize the available Charge Summary Report of procedure documentation
located in Clinical Folders.
Charges
Unit
ED
Charges per Documentation (Review Clinical Folders)
IntraOperative
GI-Urology - Minor Procedures
No Anesthesia/Local
Moderate Sedation
Moderate Sedation Charge
Anesthesia
Pre Charge
PACU I
Minute
PACU II
Minute
PCA
Per Charge Summary Report
Therapies
Labor & Delivery
37
(Rev. 7/27/2012)
Triage Patients (Outpatient)
Fetal Non-stress test
Infusions - Hydration
Hours
Fetal Ultrasound - Possible
Vaginal Deliveries
Vaginal Delivery - Single or Multiple
Epidural Anesthesia - If performed
IUPC Catheters
Catheter Foley Simple
C-Sections
C-Section Level 1, 2 or 3 per minute
Anesthesia type: General or Bolus Epidural
OR Set Up Fee
C-Section pack & miscellaneous supplies
Catheter Foley Simple
PACU Time
Minute
IUPC Catheters
Miscellaneous Procedures (i.e. D&C )
Minor Procedure time
Minute
Anesthesia type
OR Set Up Fee
Non D&C IUFD
Vaginal Delivery Charge
Repair of vaginal tear or sterilization procedure
Minor Procedure time
Minute
Anesthesia type
PACU Time (with General Anesthesia)
38
Minute
APPENDIX I – PER CHARGE SUMMARY REPORT
GI Charge Review Tip Sheet - Charges based on Anesthesia Type
ANESTHESIA
TYPE
GENERAL
GENERAL
MAC
PERIOP RECORDS YOU WILL SEE ON THE
CHARGE VIEWER
TIPS:
GI PREOP RECORD ANESTHESIA
GI RECORD
GI PACU PHASE II RECORD ANESTHESIA
(MAY SEE GI PACU PHASE I RECORD IF PATIENT
WENT TO THE RECOVERY ROOM)
IF YOU DON'T SEE PREOP OR PACU II
RECORDS:
Look in Clinical Folders and see
if/who did the documentation for the
missing record or
Look at Charge Review to see if the
record is held.
Patient sent to Recovery and Discharged from
Recovery:
GI RECORD
GI PACU PHASE I RECORD
IF YOU DON'T SEE PREOP OR PACU I
RECORDS:
missing record or
record is held.
GI RECORD
GI PACU PHASE II RECORD ANESTHESIA
IF YOU DON'T SEE PREOP OR PACU II
RECORDS:
missing record or
record is held.
MODERATE
GI RECORD
LOCAL
GI RECORD
Be sure to click the blue Preop Record Anesthesia and the blue PACU Phase II Record Anesthesia. Verify
that there is an AMB SURG FEE PRE and AMB SURGE FEE POST charge. Verify that a PCAU Phase I Record
shows a charge for Acuity Level.
39
(Rev. 7/27/2012)
LOGGING OUT
When you have completed your activities, remember to log out of the application you are working on
for security purposes. Logging out can be done in one of the following three ways:
40
1.
If you are exiting the application temporarily, but planning on returning to that computer shortly,
click Suspend User on the toolbar. This returns the screen to the log on window and place the
cursor in the password field.
2.
If you want to shut down the application completely, click Exit on the toolbar or the X in the
upper right hand corner of your screen. Keep in mind that shutting down the application will
require the next user to re-launch the application, which requires a greater amount of time.
3.
Select Exit Application, to open the Exit Application window. The first option available allows
you to prepare the application for the next user. This returns the screen to the log on window
and place the cursor in the user name field. The second option will completely shut down the
application and the third option allows you to suspend the application.

SurgiNet Charge Review

Transcription

Similar documents

Market Summary Report (BETOS groupings)

Get the paperwork licked

SERVICE CHARGES

registration form 002 copy

Electricity Facts Label (EFL) Privileged Power Pricing

Our Services Brochure - Banfields Aged Care Facilities Melbourne

How to Print Images

Business Application

EFL