1. Robert Cutrell

    Multiply this scenario by 15 for a typical day in the hospital. How is it practical to keep track of the minutes you spend on a patient throughout the day? When I am rounding in the hospital I almost never spend much contiguous time on one patient. How does one track and document minutes spent with each patient while dealing with multiple patients all day long during a 12 hour shift? What about all the minutes that come up after I’ve already documented and charged for my time but then more comes up later? This doesn’t seem like something I will ever do.

  2. Nick

    What is the verbiage required when documenting time based, can you just state how much time you spent or do you need to include what the time was spent on?

  3. Linda Duckworth

    Document the total minutes you spent for the day and be as close as possible. Avoid using time ranges such as “60 to 75 minutes”, and do not default to a CPT code’s threshold. Briefly describe the activities that consumed your time, for example- reviewing records from a previous stay, lengthy conversations, or extensive time with orders/coordinating care.

  4. Linda Duckworth

    Time should be more of an exception than rule, mainly for the reasons you cited above. For the majority of patients, you’ll be better served by concentrating your documentation efforts on fully describing the complexity of problems you’re addressing, data (lab, rads, interpretations, discussions, etc.) and developing a well-written plan (for risks).


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