Remember to keep in mind these common documentation faux pas!
Missing Chief Complaint
The chief complaint supports the medical necessity for the patient encounter. All visits require a chief complaint to be clearly documented. (Think, Follow up for hypertension, instead of 6 month follow up; or Patient seen today for…, instead of Observation day 2.)
Inconsistencies between the HPI, ROS, physical exam, and A/P can bring into question the credibility of the entire document. For example, the HPI describes complaints of abdominal pain while the ROS is negative for abdominal pain; or a female patient with negative physical exam findings for testicular masses. Documentation should always be reviewed prior to finalizing.
Significant errors can inadvertently be documented with voice recognition software. A dictated note must be reviewed for errors with appropriate corrections made prior to signing. Adding a disclaimer to the note regarding possible errors is not a substitute for correcting them.
Carry forward/Copy and paste/Cloning
Including information from prior documentation to a current note can be beneficial for certain situations; however, great care must be taken to ensure the integrity of the note and to avoid misrepresentation of the actual patient encounter. The added information must be edited with additions or deletions to make it unique and individualized to the current patient encounter.
For a diagnosis to be considered addressed, at least one M.E.A.T. criteria must be documented with it:
- Monitoring—signs, symptoms, disease progression, disease regression
- Evaluating—test results, medication effectiveness, response to treatment
- Assessing/Addressing—ordering tests, discussion, review records, counseling
- Treating—medications, therapies, other modalities
In the A/P, if a list of the patient’s conditions is followed by a paragraph of plans, this may not be sufficient to give credit for every diagnosis. Rather, the associated plan should be specified for each condition.
Incomplete Time-Based Documentation
When billing for services based on time, the details matter. If a service involves counseling for the majority of the visit, following should be documented in order to bill based on time:
- Total time provider spent with the patient
- Statement of “greater than 50% of time was spent in counseling and/or coordination of care”
- Description of the counseling discussion and/or the coordination that was involved