Clinical Documentation: Tips and Hints

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.