Key Points for IV Charting

Claiming revenue for Emergency Department services depends on the documentaion found in the patient EHR. IV billing requires all three of the following components:

a.  Start time of the infusion

b.  Stop time of the infusion

c.  How much volume was infused

The following practices are recommended for best outcomes:

1.  Make sure there is an order for each IV and IV bolus.

2.  Barcode scan all IV’s this ensures an accurate real time start time and safe gaurds the patient.

3.  Chart actual IV start times and rate change times when they occur

4.  Change rate to “0” for infusions that are completed

5.  Use MAR summary to check that you have met all the requirments for IV charting when you are finishing with a patient.

6.  Use IView/I&O to pull in volumes when you are done caring for your patient. If you have charted correct begin times and correct rate change times the hourly volumes will calculate correctly.

7.  Enter end times and volume totals in the Infusion Billing window at Depart.

Infusion Billing from Depart Process

  1. The IV Stop Times bar is yellow only if there are charted IV’s with missing details; be sure to check the MAR summary to be sure all IV/meds are charted.
  2. Charting Start/Stop/infused volume details is required for reimbursement
  3. To chart double click on the symbol
  4. Check the event box if necessary
  5. Review the Start time and enter End time/Volume details
  6. Click Sign

Bolus example: Enter data when necessary before signing.

Tips

1.  Infusion Billing software is available:

a.  Nurse-M tracking shell,

b.  MAR ,

c.  Depart Process

2.  Infusion Billing is used to capture Start/Stop/Infused information for billers. The Icon will not display if the IV piggyback was not charted or if the begin bag was not charted for IV/IV med/IV bolus. Information charted in the Infusion Billing window does not transfer to PowerChart/FirstNet.

3.  IV Stop Times tracking column is next to Activities

4.  Scan your bags, enter correct rates, and chart I&O in IView; using Infusion billing in Depart is one additional step to your normal process.

5.  At the end of your care with a patient remember to:

a.  Review MAR summary to verify

i.  all IV/meds are charted

ii. all rate changes are charted at correct times

iii.  completed infusions rates are changed to Zero

b.  Chart I&O in IView prior to Infusion billing in Depart

6.  Please NOTE: charting a volume in infusion billing does not record the volume in I&O (IView).

7.  I&O must be charted in IView for safe clinical care and monitoring of patients.

8.  It is helpful to document I&O before documenting IV Stop Times (easier to remember times and amounts).

9.  Use Activities column or MAR for Rate Change and back charting when scanning could not be accomplished

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