Documenting bedside procedures is an essential aspect of any healthcare practice. It helps ensure patient safety and provides a record of the procedure performed.
The documentation requirements for a bedside procedure do not change based on whether the procedure is performed in an inpatient or an outpatient setting. In both cases, the documentation must support the procedure provided.
To help guide this process there are 7 best practice items providers should confirm are included in their medical documentation:
DON’T FORGET TO DOCUMENT
One important aspect of documenting bedside procedures is the “time out” process. This process involves a moment to pause and review immediately before the procedure is performed to assess critical factors, such as:
- Correct patient identified,
- Side/Site is marked appropriately,
- Patient position is appropriate,
- Safety precautions are taken based on patient history.
Another one of these areas that tends to get missed is the medications used. Because anesthesia is commonly used, many clinicians think it is an inherit part of the procedure. And you are right, it is, but indicating the medications being used can avoid issues down the road with potential complications.
The last area that tends to be missed when documenting bedside procedures is the outcome. This section is important in documenting how the patient tolerated the procedure and what the final outcome is.
EXAMPLES OF BEDSIDE PROCEDURES
Here are some frequently performed bedside procedures:
- Thoracentesis
- Paracentesis
- Lumbar puncture
- Peripherally inserted central catheter (PICC) line insertion
- Insertion of a urinary catheter
- Cardioversion
- Incision and drainage procedures
- Wound Vacuums
- Central line insertion
- Declotting procedures
- Pleurodesis
- Arthrocentesis and joint injections
- Echocardiograms
- Biopsies (e.g., bone marrow biopsy)
- Cardiopulmonary resuscitation (CPR)
- Chest tube insertion
- Endotracheal intubation
- Blood transfusions
- Drug administration services
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