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4 Keys to Getting the Most Out of Your Documentation

Errors in documentation can occur along the patient trajectory — e.g., the patient doesn’t describe symptoms correctly, medical staff improperly triage the patient, the physician incorrectly interprets symptoms — or along the paper trail. When something is incorrectly entered into the documentation, it is handed through the care pathway, on to specialists or the GPs who provide follow-up care, which can compromise outcomes.

Furthermore, if your documentation isn’t up to scratch, you could be losing out on crucial reimbursements in a payment environment that continues to put the squeeze on physicians and facilities. Some examples over a variety of settings:

Reimbursement for “heart failure unspecified” is thousands less than if chronic combined systolic and diastolic heart failure is indicated, and about $10,000 less than in acute combined systolic and diastolic heart failure.  Under-coding primary care visits by not recognising the complexity level of these encounters can lose a practice approximately $40,000 per year.   Incorrectly reporting care in the emergency department can have a significant impact down the care line. For example, if an ED physician uses a global fracture care code for the application of a splint or cast, and then refers the patient on to an orthopedist for follow-up care, the orthopedist will not be reimbursed for care.

Good documentation is critical to appropriate coding and, in turn, accurate reimbursements. Equally, poor documentation can lead to problems such as misspecification of diagnosis or treatment, a change in the order in which codes should appear and upcoding — which results in overpayments. Whether on purpose or by mistake, these misrepresentations can land you as an individual or your facility as a whole in hot water with payors and the government.

So what can you do? Here are four keys to improving the quality and usefulness of charted information.

1. Accuracy. Good record-keeping should be legible, free from abbreviations (which can result in misinterpretations by coders or other healthcare professionals), and include details of the patient, date and time for every encounter. If an entry must be altered, the change should be notated and accompanied by the signature and printed name of the relevant clinician. Double-check dictated letters, notes and reports.

2. Relevance. Avoid unnecessary comments and vague comments. For example, do not write “no change” — specify the factors related to the patient’s condition that haven’t changed. Do not include inappropriate and irrelevant information, which could result in damaging legal action.

3. Completeness. The medical record should include all documentation if possible, including from GP, clinic, hospital and specialists. Using electronic records can ease compilation and minimize omissions, but intra- and inter-facility communication is crucial to ensuring completeness of documentation.

4. Timeliness. History and physical should be completed and signed within 24 hours of admission; post-op notes immediately after surgery; operative notes dictated and signed within 24 hours of any procedures; and the medical record completed within 7 days of discharge after the visit. Adhering to these timelines will help ensure information is recorded while the memory is still fresh, which will in turn enhance accuracy, relevance and completeness of documentation.

The conversion to the ICD-10 coding system means a “more advanced and robust system than ICD-9, allowing for more complex and detailed reporting” is imminent. Physicians may not be detailed enough in their documentation or knowledge of the new system — medical scribes trained on ICD-10 can help ease the transition, ensuring adherence to these four best practices, to be sure you’re prepared to get the most out of your documentation.