Educating Providers to Document Completely

1. Educating Providers to Document Completely By: Joseph Newsome, CPC, CPC-I, CEMC, HCS, HAS

2. Why Document? • It is not just for reimbursement purposes • When it comes to patient care, one of the most vital tools a doctor has is good documentation

3. Chief Complaint • One of the first things that goes into a patient record is the Chief Complaint (CC), or reason the patient has come to the doctor. The CC is described briefly, be it a list of symptoms, a preliminary diagnosis or a visit on the recommendation of another physician. This description is usually stated in the patient's words

4. History • History includes the history of the CC, including factors like location, severity and modifying factors. It also includes a review of body systems that may be affected by the CC • Chief Complaint • History of Present Illness • Review of Systems • Pas, Family, Social Histpory

5. HPI • Location • Quality • Severity • Timing • Context • Modifying factors • Associated signs and symptoms

6. Review of Systems • An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. • Helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected…

7. Past, Family and Social History • Past: illnesses, injuries and treatments • Family: cause of death and diseases • Social: Age appropriate review of: • Marital status • Occupation • Drugs, alcohol and tobacco • Education • Sexual orientation and history, etc…

8. Physical Examination • Exam may be limited to relevant regions of the body or may encompass a broader examination. The findings of the examination are noted in the patient record

9. Diagnosis, Treatment and Risks • The doctor must note the diagnosis or diagnoses, if necessary. He/she must also record possible treatment and management options, the amount and complexity of the data to be reviewed, and the risks of complication or mortality associated with the diagnosis and treatment

10. Referrals vs. Consultations • If a referral is required, the doctor must document it, noting which doctor he/she is referring the patient to • Necessity • Transfer of Care • Consultation Request • Details are important

11. Education & Follow-up • The doctor must also make note of any: • Information given to the patient regarding his diagnosis and/or treatment • Any recommendations for follow-up care, including further visits • Planned Treatment • Etc…

12. Documentation • The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: • The ability of the physician and other health care professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her health care over time

13. The Medical Record Facilitates: • Communication and continuity of care among physicians and other health care professionals involved in the patient’s care • Accurate and timely claims review and payment • Appropriate utilization review and quality of care evaluations

14. The Medical Record Facilitates • Collection of data that may be useful for research and education

15. General Principles • The medical record should be complete and legible • The documentation encounter should include: • CC, History, Examination, findings • Assessment, clinical impression or diagnosis • Plan of care • Date and legible identity of the observer

16. General Principles • Rationale for ordering diagnostic and other ancillary services • Past and present diagnoses accessible to physician • Appropriate health risk factors identified

17. General Principles • Patient’s progress: response to and changes in treatment, revision of diagnosis • CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record

18. Corrections to the Medical Record • Under federal law, record falsification is viewed as submitting false claims. Record tampering undermines a clinician’s credibility in the event of litigation. • It is important not to jeopardize the integrity of a patient’s medical record by using a questionable correction method.

19. Corrections to the Medical Record • Guidelines in making proper medical record corrections: • Do not add or clarify an entry after you have received a subpoena for records • Never make entries in pencil or erasable ink • Never attempt a correction by erasing • Never obliterate an entry or use correction fluid

20. Corrections to the Medical Record • When a correction becomes necessary, merely draw a single line through the entry so that the original entry is still readable. • Make a notation explaining the correction, or directing the reader to the appropriate addendum. • Date and sign the correction

21. Addendum • Is using an addendum, place it in sequence or chronological order

22. Documenting Reminders • Using modifier 24 • Using modifier 25 • Reporting time based codes • Prolonged Services codes