Understanding Medication Administration Records, Smart Pumps, and Documentation

As you may know, it is becoming common for hospital organizations to utilize smart pumps and associated documentation systems to capture the time of fluid and drug administration while enhancing charge capture for drug administration. Some products contain standalone charge capture solutions while others feature interoperability that communicates with the hospital electronic medication administration record (MAR).

However, understand that the standalone solutions do not normally replace the documentation of drug administration in the MAR.

The nursing documentation in the MAR must support the drug administration charges reported. Why is this a requirement? The documentation is critical since there is often a discrepancy of the infusion time increment based on the time recorded by smart pump versus what nursing documents in the MAR. The interoperability solution is designed to capture the begin and end times (start and stop) of infused fluids and medications.

Why is bidirectional communications necessary? Bidirectional communication between the medical record and infusion pump is meant to decrease risk of medication errors while increasing safety and decreasing staff time associated with documenting infusion times. Regardless of the type of documentation and charge capture systems your facility uses, continue to periodically check nursing documentation practices against billed claims to ensure the drug administration charges and units are appropriate.

Documentation Tips 

It is an absolute requirement for a patient encounter in the outpatient infusion department to be documented extensively. Documentation is necessary to support the capture of all charges while justifying the level of services provided to patients. This documentation is not limited to the procedure or treatment, but also includes records of patient acuity, monitoring of the results of the service, ongoing treatment and evaluation, disposition, and the length of time spent with the patient by both nurses and physicians (if applicable).

These additional documentation requirements support payment and protect the provider in the event of an audit of patient medical records. The primary patient encounter documentation in the outpatient infusion department is the treatment record, which provides the key clinical input for accurate and complete charging, coding, and reporting of services. If nursing staff do not adequately and consistently document services provided, the subsequent charging and coding steps cannot be performed with the highest level of quality. The outpatient infusion report must include the following treatment information:

• Drug or substance

• Dose

• Route

• Site

• Rate

• Start and stop time of each drug or substance infused

• Flush

Why is complete and comprehensive documentation essential? It is essential for reporting outpatient infusion services for several reasons. One is that data quality and payment depend on accurate and complete inputs and outputs in the form of records created by infusion staff. Documentation is also necessary to support and justify the facility and physician charges. Furthermore, coders need complete and timely documentation to accurately assign the codes that best describe patient services (and that are required to bill claims). Lastly, third-party payers such as Medicare perform periodic audits of provider medical records to ensure that a facility can justify the charges on the claims it submits, as well as to ensure the quality of care.

Master more everyday challenges and find further educational insights by utilizing our Coding Essentials for Infusion & Injection Therapy Services.