I strongly feel that most physicians don't understand the link between what they write in a medical record and what the hospital, and they get paid. Nor do they understand the very real risks of fraud and abuse charges that can result from patterns of errors.
Understandably, healthcare providers put patient care first and we wouldn't want things any other way. When I'm called to see a patient with chest pain, writing a detailed note is just not the first thing on my priority list. Too often though, providing excellent patient care is used as an excuse for very poor documentation.
Some physicians feel that writing good notes isn't their concern -that they have PA's, NP's or residents to do the work. Some don't see the link between quality care and documentation and think that as long as their patients do well, that's all that really matters. Of course everyone is stressed for time and so notes are dashed off all too quickly. And some physicians honestly don't have the information they need to do a better job of documenting.
The fact is, we physicians haven't been taught very much about documentation in medical school or training. We usually get a general introduction to writing histories and physicals, and documenting to the problem-oriented medical record. We get some legal tips on documentation practices aimed at reducing professional liability risks. But when it comes to writing detailed notes that justify our medical care decisions, well, that medical school class never happened.
Leading Documentation Errors
Here are some examples of the documentation errors I've seen translate to denials and dollars:
1. Tops on my list: the lack of justification. I want to say, "Tell me, Doc, why does this patient need inpatient care instead of observation? Why does the patient need to stay another day?" Physicians need to remember to use the word "because" as in "The patient needs to stay another day because his hemoglobin has not stabilized and he continues to complain of dizziness."
2. Too often problem lists are made, but no diagnoses are suggested, or the principal diagnosis is not spelled out clearly.
3. Physicians don't fully explain the impact of co-morbid conditions and complications.
4. Handwritten notes are completely illegible, and times and dates are missing and finally,
5. Electronic medical records are cut-and-pasted without updating.
All of these poor practices can lead to erroneous coding, improper DRG calculations, and denials. What's more, for those of us in denials management, these practices make it very difficult to write strong appeals.
Physician Involvement: The Key
So, what are hospitals to do? It's critical that hospital compliance programs hit their marks, and physicians must be part of the process. Hospitals need to approach these issues from several directions by undertaking the following:
1. Regularly reviewing hospital and physician performance statistics
2. Providing physicians feedback with data on dollars lost and denials gained
3. Creating documentation aids, electronic or paper, that make it easy to do the right thing
4. Educating physicians in ways that are simple and direct and,
5. Establishing on-going, short, structured, small group information exchanges between medical records staff and physicians with everybody leaving their egos at the door
The bottom line is it takes a multipronged, customized and creative program to ensure that everyone - including physicians - plays their part to comply with the rules and reduce the risks of denials.
About the Author
Cynthia M. Lipsitz, MD, MPH, is a Senior Medical Reviewer with Washington and West, LLC, an appeals and denials management company. In this capacity she maintains familiarity with current standards of medical care, Medicare and private payer hospitalization criteria, and coverage policies. Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials. With over 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.