Solutions to the documentation problem are not easy to find, and all come with both pros and cons. Paper or electronic templates offer some advantages, but it's all too easy to leave great portions of them blank. Another option is to cut and paste sections of electronic notes, and wind up with the same documentation day after day. This practice, however, increases the risk of repeated inaccuracies and miscommunication. Standard-order sets offer the advantage of guidance based on medical evidence, but their decision algorithms can be frustrating and difficult to follow.
Documentation specialists and coders have their own set of headaches in this area. Identifying the ideal physician query, one that is timely, succinct, and actually gets a response, is the subject of many a conference, webinar or newsletter. It's often tough to design a question that is clear and specific but doesn't suggest a response.
The longer I work in the field of denials management, medical coding and documentation improvement, the more I doubt that the holy grail of clinical documentation ever will be found. But I do think that there are some simple reminders that can help clinicians improve their documentation skills. Here's the latest.
Think like a professor, write like a medical student. If we were to combine the thought processes and communication skills that we've acquired in our clinical experience with some of the lessons we learned as students, I believe our documentation would improve.
Think Like a Professor
Remember teaching rounds? Skilled professors or attending physicians would guide their students through the thought processes necessary to formulate a differential diagnosis and explain the rationale for decisions and plans. The best teachers had
- An extensive reserve of knowledge
- The experience to anticipate the sequence of events that a workup should follow
- Excellent reasoning to justify their actions; and
- Crystal-clear communication skills that make them easy to understand.
These are precisely the elements that are needed in physician documentation. If only the physician would write down what he thinks is happening with his or her patient, how severely ill they are, what direction he wants his workup to follow, his patient's anticipated service needs, and why his plans are necessary. Then, the reader of the medical record - be it medical student, colleague, coder or auditor - would be more likely to understand and use the documented information appropriately, according to their individual needs.
Too often, though, the serious consideration that a patient's care is given simply is not documented. The quality of care may be outstanding, but the hospital and physician won't get paid for it. Auditors will claim that "there is no documentation to support the medical necessity of this patient's admission and continued hospital stay," and deny the claim.
Write Like a Medical Student
In general, medical students are taught to write progress notes that include at a minimum:
- Patient's name and date of birth on each page
- Date and time
- Subjective statement - usually what the patient actually states
- Objective statement - vital signs, physical exam with pertinent positive and negative findings, labs, imaging, procedure results and basically anything else that has been objectively determined
- Assessment - number each problem and discuss it: is it stable, improving, worsening? Ideas about its cause? Are other problems complicating it? Have there been any other complications? What has the workup to date told you, and what more might be needed?
- Plan - more testing? More intense services? Does the rest of the workup depend on any pending test results? And why is it necessary to do these things? Justify your decisions.
- Signature (legible, of course), printed name and identification number
During internship, residency and fellowships, we learn more specific documentation standards as determined by our specialty. Thus, surgeons learn procedure and operative notes, OB-GYNs learn delivery notes, pediatricians learn NICU notes, etc. But the fundamental lesson is to document thoroughly, accurately and clearly.
Putting the Two Together
It IS possible for healthcare professionals to write better notes, not only to improve quality of care but also to ensure that they and their hospitals get paid for their work. It is critically important to document daily the severity of the patient's illness and why they require a particular intensity of services. Medical records need to clearly reflect the provider's thought processes and justify the patient's need for services at a specific level of care.
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.
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