I wrote the article below for Dr. Rob Olson with
ObGynHospitalist.com This information is applicable for all specialties. enjoy! L : )
We
have all heard the adage “if it wasn’t documented, it wasn’t done”. However, for physicians, the fast pace of the job can get in the way of the accuracy of
documentation. The way to remain fiscally solvent, is by accurate coding and billing, and providing good patient care. Clinical
Documentation is a fundamental piece of the total job function.
The
importance of clinical documentation cannot be underestimated. Medical documentation is essential to ensure
high quality medical care for your patient throughout the continuum of
care. Good clinical documentation both
to and from all medical providers (physicians, nurses, PT/OT, etc) benefit not
only the patient, but also your revenue stream.
If your coder/biller is able to quickly decipher and bill the claim it
means the reimbursement will be back to your practice that much faster. Good documentation supports medical necessity
for payment and clarification of services provided to your patients, especially
if they have an emergent visit, or unexpected clinical finding upon testing.
The
term ‘medical necessity’ has become commonplace verbiage with insurance
carriers. Your clinical documentation
will be the first thing requested for audit or review, if there is a question
regarding payment for your services.
Outlined
below are a few quick clinical documentation tips and hints to help clarify
your clinical record documentation.
A) The medical record should be complete and
legible
Documentation for each encounter should
include:
§
Reason
for the encounter and relevant history, physical exam findings and prior
diagnostic test results;
§
Assessment,
clinical impression or diagnosis
§
Plan
of care
§
Time
spent (eg face to face/counseling-coordination of care)
o
Documented
time in
o
Documented
time out
o
Documented
total time spent (eg at bedside, on monitor(s), etc)
§
Date
and Signature
§
The
rationale for ordering diagnostic and other ancillary services
§
Past
and present diagnoses (If pertinent to the encounter)
§
Appropriate
health risk factors should be identified (if pertinent to the encounter)
§
Patient’s
progress, response to and changes in treatment and/or revision of diagnosis
B) Avoid Ambiguous Language
Eg.. “Non-contributory” : The term
“non-contributory” is good example of
ambiguous documentation. In some
instances, a provider intends the term to mean the body system was not
relevant, therefore was not reviewed... while another provider may intend that
verbiage to mean that the body system was reviewed, but had no pertinent
findings to be reported. Be clear,
concise and relevant by avoiding using the term “non-contributory”.
Another term that can be misconstrued is
“abnormal” be sure to clarify, qualify,
or quantify what is “abnormal”.
C) Clarify your diagnosis
“For a presenting problem with an established diagnosis
the documentation should reflect whether the problem is:
a) improved, well
controlled, resolving or resolved;
b) inadequately controlled, worsening, or failing
to respond/or change as expected
“For a presenting problem without an established
diagnosis, the assessment or clinical impression can be
stated
a) as a “possible”,
“probable”, or “rule out” (R/O) diagnosis,(such as rule out kidney stone)
b) and should also denote any signs and/or associated symptoms in your
findings (such as pelvic pain, sinus pressure etc)
D) Ordering of Tests
and Procedures
Clinical documentation guidelines state that
the rationale for tests/procedures should be ‘easily inferred’, but suggest
clearly documenting the reason(s) for any testing or procedures
§
document
‘what’ test/procedure is being ordered.
(i.e. Fetal NST, fetal fibronectin)
§
document
‘why’ the test/procedure is being ordered (i.e. decreased fetal movement)
E) Omitted Information
In the event information is inadvertently
forgotten, delayed, or omitted from the medical record, it is acceptable to
amend the record. “Late entries” are also acceptable however, should be used infrequently.
Acceptable methods for recording “amendments”,
“addendum” and “late entries” follow:
•Create a new entry for the additional
information
•Do not annotate in the margins to add
information
•Keep all entries chronological and in record
sequence
•Title or head the entry or note as “Addendum”,
“Amendment” or “Late Entry”
•Use the actual date of the addendum, amendment
or late entry
•Reference the original entry or document by
indicatingthe date of the service
•Always sign the additional entry or document
Documentation
will always be a “necessary evil” in the role of healthcare and
reimbursement. The conversion to ICD-10
cm will take place October 1, 2014, and providers will be tasked with providing
better documentation with this new diagnostic/diagnosis system. Your willingness to improve your clinical
documentation now, will only make it easier for you to adapt and continue to
provide excellent patient care in the future.
