Q&A: Documenting continuous infusions for observation patients

Q: What are the documentation requirements for a continuous infusion for an observation patient? For example, for a hydration infusion consisting of sodium chloride ordered to run continuously over 24 hours, or a Taxol® chemotherapy infusion ordered to run continuously over 21 hours, what documentation would be expected, especially spanning the midnight hour? We often see rate change or rate verification notations during continuously running infusions, but would a start and stop time be required or expected for each bag change?

A: As every bag is changed, you're going to scan the barcode on that new bag. You would typically see on a medication administration record (MAR) a start time for each bag that's running continuously, and then you might see a confirmation of the rate. You would see the in-and-out record that basically that patient's output is consistent with the amount of fluid that they're getting in, and then you would see the overall end time at the end of the continuous infusion.

So yes, you would see that start time, and if you use a special report where you actually take your MAR and you have your custom report built post-discharge that takes all of the oral and other medications out and organizes it by drug, by route in date order, you would consistently see with that continuous infusion those start times of those bags without any end times. You would then see the overall end time and you can clearly see that it's continuous.

I think the most effective way to capture drug administration services is to have a custom MAR report built that really makes it straightforward, follows the hierarchy, and sorts it by drug and by route. It makes it very effective to train staff so that you're not using your nursing services to capture charges or your certified coding services to capture charges but rather trained personnel using this special report.      

Editor’s note:  Valerie A. Rinkle, MPA, lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp®, as well as an instructor for HCPro’s Medicare Boot Camp®—Hospital Version and Medicare Boot Camp®—Utilization Review Version, answered this question on the HCPro webinar “Improve Documentation and Coding for Injections and Infusions.”

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