Most nurses in the field no longer code and yet they remain the most important source of information when it comes to assigning ICD-9 codes. In the majority of cases, a good assessment will tell the coder everything they need to know but not always. If the coder isn’t certain of how to code, there is a good chance the care plan and documentation that follows will be inadequate resulting in a denial should the claim ever be reviewed.
That’s where a good admission summary comes in handy. A lot of agencies have let the summary go by the wayside as it is not technically required anymore. I bet your next paycheck that agencies who write summaries are denied less often than those who do.
A summary can be a long and boring narrative put together from a template that reads exactly the same as all the other summaries in the agency or it can be as simple as answering a few simple questions.
You can find a summary worksheet here to use as a sample. Most computer systems will allow you to create templates. If not, a summary can still be created using these questions, modified for your agency’s use, if the responses are in complete sentences.
There is no right or wrong way to write a summary. Nurses who do not like to write often find it difficult and time-consuming. Using a tool to order thoughts and facts can be of enormous use.
Depending on the software you use, you may want to add vital sign ranges. Some software will print lists or summaries of vital signs for you. The med list should always be attached to recertification paperwork so questions about meds can be answered. You would be amazed at how often medications change from one episode to the next without an interim order. This worksheet along with a current med sheet will allow you to document what has gone on with the patient’s med regime so that the skilled care provided will be evident.
Most important, pretty much any coder can work from a sheet like this. It does not matter if the skilled nurse knows that two codes are needed for a pressure ulcer if she documents a wound to the left heel.
Patient care has become increasingly ‘technical’ but historically good patient care has always been a combination of science and art. By off loading the technical task of sequencing coding, the nursing staff is able to devote more time to the art of caring while coders solve the ICD-9 coding puzzle but only if the coder has all the puzzle pieces.