Documentation
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The document outlines guidelines for proper medical documentation. Correct documentation is important for continuity of patient care, facilitating treatment decisions, supporting insurance claims, and providing a legal record. Documentation should include the chief complaint, history, exam findings, assessment, diagnosis, treatment plan, date, and author. Entries must be dated, timed and signed. Non-descriptive language and block charting should be avoided. Documentation must support any insurance billing and be maintained confidentially.
Documentation
- 2. Objectives Participant will be able to identify reasons for correct and supportive documentation. Participant will be able to identify practices to avoid. Participant will be able to identify errors in chart documentation
- 3. Medical Record Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including the past and present illnesses, examinations, tests, treatments, and outcome. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record should be complete and legible
- 4. Proper documentation 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. Communication and continuity of care among the physicians and other health care professionals involved in the patient care.
- 5. Continued Accurate and timely claims review and payment. Appropriate utilization review and quality of care evaluations. Collection of data that may be used for research and education.
- 6. Basic principles of documentation Documentation of each patient encounter should include or provide reference to: Chief complaint and/or reason for the encounter. Relevant history, examination findings and prior diagnostic test results.
- 7. Assessment, clinical impression or diagnosis and plan of care. Date and legible identity of health care professional. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement must be supported by the documentation in the medical record.
- 8. The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law.
- 9. Documentation Guidelines Be specific For example: abd dressing changed. Incision clean, dry and intact. No drainage noted. 2 ABD pads and abd binder applied.
- 10. Use objective statements For example: pt states “if I don’t get my pain medication, I am going home.” Pt pacing in room, throwing tissue boxes at nurses.
- 11. Remember this is a legal document and is discoverable. Everything you write becomes part of that legal document. For example: “Pt smoking in room. Explained hospital policy of no smoking in the building. Pt verbalized understanding of hospital smoking policy.”
- 12. REMEMBER – EVERY ENTRY MUST BE DATED, TIMED AND SIGNED!!!!!!!! Recent audits of this facility show that less than 10% of entries have all three components. This is not only a legal issue, it does cost our facility many $$$$ if we are unable to track what occurred when.
- 13. IF IT WASN’T DOCUMENTED, IT WASN’T DONE!!!!!!!!!!!!!!! Again, not only a legal issue, but a monetary one as well. As RAC and private insurance companies start to audit our charges, we need to provide the documentation to support it.
- 14. What to avoid Non descript language - “abd dressing changed” - “dilaudid effective” Bad habits such as - not signing notes until end of shift - block charting - judgmental language “pt was carrying on”
- 15. Avoid Naming individual staff members when patients express concerns “ pt states Sue RN is mean. She states Sue RN never gave pain med when asked” Should read “pt expressed concern over not getting rx medication for pain. Lori Smith RN, supervisor notified.”
- 16. The documentation you provide is used to track the patient’s care through his/her stay at our facility. It is also used to provide support for billed charges. Your documentation can also be the shield that protects you from unwanted consequences.
- 17. Questions?