I was thinking on how the clinical documentation can make the tracking of NRS supplies better and easier.
NRS supplies are sometimes difficult to track down in the clinical record, I am wondering if this occurs in other agencies as well? It's required for final billing, so this is another item the agency's back-office has to review before final billing. And many QA staff and billing staff can easily miss that, not to mention field nurses as well. So getting it from the start where field nurses are involved and document that needs that much more development.
And making that easier would help tremendously on time and essentially money in many aspects.
Currently there's just a button, "Add Supply Worksheet" on each clinical note at the bottom and honestly clinicians skip it. They honestly skip it, and I believe it happens all the time in any agency. Nurses document it in their notes but that may be it, and are quicker to electronically sign the document and be done with it.
Programming needs to be developed to capture that, and that can be as simple as selecting the catheter device, size, and date (as how it is currently) and migrating that selected data into the Verify Supplies tab of the Final Billing process, yes?
Further capturing other documentation of NRS data in the Wound Care Flowsheet. Treatment Performed may need to be modified and re-structured to select supplies used (Cleansed with... normal saline, gauze, etc.; Applied... medication, hydrogel, wound filler, etc.; Covered with... alginate, foam, w/ or w/o adhesive border, etc.; Secured with... tape, waterproof tape etc, etc...) So as the clinician selects types of supplies used, this further migrates to Verify Supplies in Billing.
I also think we need to have the ability to Nickname the many NRS supplies without changing it's description, because what's important is getting the right HCPCS code, and honestly nurses do NOT know and really DON"T care about that list, it's too much reading which supply description it is as nurses just want the brand name, so I would nickname that supply description accordingly. Which further explains clinicians skip the Supply Worksheet button in their notes.
OASIS's Supplies and DME tab can also be changed and assessment boxes within the OASIS as well where NRS supplies are used and documented.
Capturing any NRS supply data where the clinician would document it is what needs to be captured and migrated into the final billing data would be great, I think.
So just some things I thought about.