August 2018

August 2018

The Purpose of Documentation

The “Why” is Important

As providers strive to adhere to compliance standards, there has been a rising concern over how this affects patient record documentation. Even seasoned doctors become frustrated with the many required pieces of documenting patient care. It is no longer acceptable to simply treat the patient as you see fit and note the date that the patient was seen in the office. And it shouldn’t be.

There is an old saying… “If it’s not included in the medical record, it never happened.”

The patient’s medical record is a legal document, and as such, should be able to withstand scrutiny. It provides a detailed, and accurate account of every aspect of the patient’s care while in your office. There are several reasons behind the documentation requirements, but we chose to simplify it by focusing on what we consider to be the three main purposes of documentation:

  • To contribute to and provide a record of quality patient care
  • To secure appropriate reimbursement based on requirements
  • To provide an accurate record of what happened

National Committee for Quality Assurance Guidelines

Now that we know why we document, let’s briefly review what is required. The National Committee for Quality Assurance (NCQA) set the guidelines for what is considered proper medical record documentation. Their list contains twenty-one (21) different commonly accepted components; the list below indicates the minimum requirements:

  • Patient Identification
  • Personal/Biographical data
  • Provider Identification
  • Entry Date
  • Legibility
  • Problem List
  • Allergies
  • Past Medical History
  • Physical Exam
  • Smoking/Alcohol/Substance abuse
  • History and Physical
  • Working Diagnosis
  • Plant/Treatment
  • Patient Education/Instructions
  • Consults/X-ray/Imaging Reports/Referral Records
  • Follow Up/Clearly documented return visits
  • Clear Case Management

Indicators of Poor Documentation

To avoid raising red flags with your documentation, it is best practice to strive to be as neat, accurate, and concise as possible the first time around. Some indications of poor documentation include:

  • Pencil/white-out/erasures
  • Illegible documents
  • Non-standard abbreviations
  • Missing dates
  • Absence of signatures
  • Blank/Incomplete spaces
  • Missing identifying information on each page
  • Undocumented consents
  • Colored ink (other than black/blue)

Correcting Documentation Errors

Addendums to notes are necessary at times under the appropriate circumstances, and within a timely period. However, these additions should be made to improve the accuracy of the record, not to change it. Remember, some corrections are permitted. Strike one line through it (not multiple lines or scribbles), make your correction, and authorize any change with your initials and the date it took place. Strive to make your documentation read like a book. The easier a chart is to read, the better it will be upheld under scrutiny.

Do you need help implementing a documentation system that is personalized and easy to use? The Paperwork Project can help