Improving your critical care documentation

When should you think about documenting critical care time?

Whenever you take care of someone with a life or organ system threatening injury or illness and you do something to save their life, you should consider critical care. Some examples of things you do or diagnoses you manage that may fit this definition are found below. You won’t perform critical care every time you do or diagnose the following but you should consider it every time. For instance, a patient with a hypertensive crisis with end organ dysfunction in the field may need to be admitted but if EMS stabilized them in route, you might not get credit for the critical care. What should you document? Always document the critical diagnosis, what you did, how much time you spent and that it was exclusive of separately billable procedures. Remember that critical care time does not include separately billable procedures.

Remember that time spent can be with the patient or in the department doing things for that patient such as looking at labs, x-rays, speaking with consultants, surrogates, and documenting the record. The clock does not have to be continuous so 3 separate 15 minute time periods do equal a total of 45 minutes, but the clock stops when you or the patient leaves the floor. A good example of a critical care statement would be

“54 year old male with sepsis, hypotension, tachycardia requiring IVF boluses, central line, IV antibiotics, stabilized, going to the floor, but critical on arrival. Time spent exclusive of separately billable procedures (central line, CPR, intubation, shoulder reduction, etc.) was 40 minutes.”

If a PA and physician were involved in the case, call out your portion and the PA’s separately in a statement like

“I Dr. Friedenson performed 45 minutes of critical care exclusive of the PA’s time.”

Diagnoses Admit to Location IV drips or more than one IV dose of the following meds Procedures
ACS Cath LAb Amiodarone BiPap
Cardiac Arrest ICU Atropine Chest Tube
Dissection Interventional Radiology Diltiazem CPap
Epidural Hematoma OR Dompaine Crycothyrotomy
GI bleed PCU Epinephrine Intubation
Hemorrhage   Esmolol Vent
Hemothorax   Heparin  
Ischemic Bowel   Hydralazine  
Liver Laceration   Labetolol Consults
Malignant Hypertension   Levophed Neurosurgery
MI   Narcan Trauma
Necrotizing Fasciitis   Neosynephrine Vascular Surgery
Pneumothorax   Nicardipine Interventional Rad
PRES   Nitropruside Stroke Neurologist
Respiratory Arrest   Norepinephrine Cardiac Surgery
Ruptured AAA   Octreotide  
Ruptured spleen      
Splenic Laceration      
Status Epilepticus      
Subdural hematoma      
Tylenol OD

Unstable Angina