Product documentation challenges

One issue I’d like to talk about that’s not commonly discussed is that usage documentation by nurses and techs is notoriously inaccurate. There are a number of reasons why. First, clinical information systems are difficult to use for product documentation (descriptions missing, truncated or inaccurate, items missing, items difficult to find, etc.). Second, preference cards or case carts are not up-to-date with what’s actually needed by the physician for a given procedure. Third, oftentimes items other than those on preference cards end up being used in the procedure, but left out of the documentation. And finally, a significant number of items on the case cart that end up not being used for a procedure are often erroneously charged to the patient as part of the entire cart.

We studied this issue from a billing standpoint at one hospital and found that among 100+ cases examined, every single case had product documentation errors. In other words, there was a 100% error rate. These errors involved both over-billing and under-billing. Over-billing is a particular problem as it basically signifies insurance/medicare fraud – even if it is involuntary.

In addition to billing-related concerns, there’s also a matter of accuracy for the patient’s clinical record. While we can correct inventory data, it is far more difficult, if not impossible, to track down and correct this data in the patient record once the mistake has been done. These issues can easily be averted by putting in place the right practices and technology to enable easy and accurate capture of items used for patient care.