Take The Guesswork Out Of The Legalities Of Documentation

Take The Guesswork Out Of The Legalities Of Documentation

Medical records can be a critical element in legal proceedings, with improper documentation a leading cause of major medical liability. Thorough and proper documentation is essential to safeguarding providers against any type of healthcare malpractice claims.

Take The Guesswork Out Of The Legalities Of Documentation

Don’t Get Burned by Dodgy Documentation

Providers should regard documentation as a means of getting paid, but also as their best defense in malpractice litigation. Poor record-keeping can mean the difference between a indefensible lawsuit and one that can be substantiated in court.

Tip: Document all patient encounters as though anticipating litigation. Ask yourself, What information would be considered essential in a malpractice suit? How would we defend ourselves against negligence? Then document accordingly.

In Hindsight: Are Old Ways Sometimes Better?

Handwritten documentation was probably simpler and better than EMR-era documentation. Physicians, without the benefit of shortcuts, like drop-down menus and carry-forward features, were once forced to process and fully document every patient encounter, often for transcriptionists.

Today’s conveniences lend themselves to more mistakes, while the safeguards built into an EMR aren’t always sufficient or not fully utilized. A note that summarizes a clinical encounter might not be adequate to ensure payment or defend against lawsuits. Providers, through a lack of training or understanding, often neglect to cover the weak spots targeted by malpractice litigation.

Adding to the burden, healthcare now has a clinical versus business side, where providers must document to capture not only the quality of care provided, but also the necessary information for coders who will be submitting the charges to the payers. Providers frequently find themselves at odds with the billing team and practice manager, as each works toward different objectives.

It’s important to have strong communication strategies in place to clear up confusion and avoid conflict. You’re all on the same team with a common objective—providing excellent patient care. Everything builds from there.

Nail Down Documentation from a Provider’s Perspective

Many physicians struggle to keep pace with the ever-evolving practice of medicine. While in their first year at medical school, they’re trained to write a thorough note. By the time they’re in their internship, they’re told to hurry up. This duality in their role relegates documentation to the backseat and eventually makes a coder’s job harder.

Unless physicians receive on-the-job instruction, they’re not trained to accommodate the coder’s requirements, which includes the level of specificity necessary to obtain full reimbursement.

Avoid Documentation Disconnect

As coders, it’s your job to onboard your physicians. Consider these few suggestions:

  • Encourage providers to make small documentation changes that help support a higher level of service.
  • Coders and practice managers can use examples of incorrect or insufficient documentation as opportunities for training providers. Instruction should be tailored toward specific questions or areas of concern, either in one-on-one personal sessions or via large-scale, continuing education seminars, followed up with handout resources that practitioners may easily consult for reminders.
  • Consider laminating these CDI resources, or offering them in a well-labelled binder with sheet protectors, to increase the likelihood of their long-term retention. Anything you can do to give your physicians easy and convenient access to references puts you ahead of the game. You also send a message to your clinical team that you’re doing your best to simplify and streamline the process.
  • Conduct monthly documentation audits, starting with a few charts per provider. A regular routine of random checks helps practices get in sync with audit requirements, while identifying holes in EMR record-keeping.

Such habitual simulated procedures allow practice managers to observe faults and weaknesses – heading problems off at the pass. A system of monthly audits can help practices avoid the pitfalls that tend to overwhelm most unprepared clinics.

Author bio: Deborah Marsh, JD, MA, CPC, CHONC, is a senior content specialist for TCI SuperCoder, working on everything from online tool enhancements and data updates to social media and blog posts. Deborah joined TCI in 2004 as a member of TCI’s respected Coding Alert editorial team.

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