Like a broken record, health information management (HIM) professionals have repeatedly warned physicians and other clinicians about the importance of medical-record documentation by saying, "If it's not documented, it wasn't done!"

With advancements and challenges such as the evolution of electronic health records (EHRs), complex reviews by recovery audit contractors (RACs), and implementation of clinical documentation improvement (CDI) programs, it may be time to change our tune to "if it's documented, it better have been done!"

First and foremost, the purpose of medical-record documentation is to support patient-care activities. Of course, this same documentation is also vital to other activities such as coding and reimbursement, level-of-care determination, quality and core-measures reporting, medico-legal support, and healthcare statistics.  Hospitals and physicians continue to be challenged by the task of documenting a complete and accurate medical record that supports both the medical necessity of admission and code assignments in an efficient and effective manner.

The Challenges of Electronic Records

With federal and state incentives to install and meaningfully use EHRs, hospitals have been transitioning from paper to hybrid or fully electronic records. In the paper-record world, an inpatient record had a definite beginning and end, just like reading a book, but the electronic inpatient record is not so static. EHR systems allow for certain data elements, such as allergies and medication lists, to be continuously updated, which makes it challenging to get a snapshot of information for a particular date and time.

Some EHR systems also allow for previously recorded information from other encounters (inpatient, outpatient or even the physician's office) to be pulled forward into a new visit record, which makes it challenging to know what is relevant to the current encounter.  The use of templates, canned text, and cut-and-paste features can be convenient methods for capturing physician documentation but can lead to large volumes of information being collected without a lot of added value.

For example, a dictated history and physical (H&P) may result in a two-page transcribed document while a templated H&P may result in an 8-10 page report without added quality in the documentation.

Another challenge with the EHR requirements for inpatient records is the addition of a problem list to capture current, chronic, probable and/or resolved problems (i.e., diagnoses) as discrete data elements. To accomplish this, EHR systems link the problems to ICD-9-CM or SNOMED codes to allow the physicians to select from a list of problems versus having to enter this information as free text. The code descriptions associated with the problems can create challenges for physicians to select the correct one.

For example, a physician may intend to record a remote history of a myocardial infarction and actually record what appears to be a new acute myocardial infarction (MI). An up-to-date problem list could be a very beneficial addition to the inpatient record if properly implemented and maintained.  The current state of problem lists at many hospitals makes it challenging to refer to this information for code assignment or other purposes.

Importance of Documentation Grows

Early efforts of the RACs for complex reviews were primarily focused on validation of DRG assignment.  Most recently, the majority of published issues for complex reviews have been related to medical necessity of inpatient admissions. This puts the reimbursement of an entire inpatient claim in jeopardy.

According to the Medicare Benefit Policy Manual related to coverage of Part A inpatient services, "The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs. Factors to be considered when making the decision to admit include such things as the severity of the signs and symptoms exhibited by the patient and the medical predictability of something adverse happening to the patient."

Physician documentation should focus on documenting these elements to paint a picture of the patient's clinical findings and the plan for the hospitalization. A good narrative note from the physician that includes the clinical rationale for admission can be essential to justifying medical necessity.  Physicians also should consider the discharge summary as their last opportunity to include information to support the need for inpatient admission, confirm or deny diagnoses, and/or to identify any uncertain conditions that had an impact (i.e., work-up, resources, treatments, and planned follow-up) on the hospitalization.

In addition to improved documentation, hospitals should confirm that they are meeting all of the elements in the utilization review section of the Medicare conditions of participation (CoP) (Title 42, Code of Federal Regulations [CFR], section 482.30). Effective case management, utilization review and physician-advisor functions are vital to a hospital's success in assigning the appropriate level of care.