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CLINICAL DOCUMENTATION STRATEGY; TAMING THE TEMPEST

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CLINICAL DOCUMENTATION STRATEGY; TAMING THE TEMPEST

No Dorothy Gayle, you are not in Kansas anymore. You may feel, as though, you are forever trapped in the swirling, sucking vortex of the tornado, ever peddling with no forward momentum only circling. Yet you are not the victim of some traumatic head injury that has caused altered mental status and loss of consciousness. No, the tornado we face is no grandiose hallucination but the tempest of Health Care Reform. This tangible compilation of rules and regulations must be adhered to in order to retain fiscal and professional health.

 

Yet as with all dreams, we awake and find we are in the same place but viewing with different eyes. Survival is dependent on one thing, alteration of the words you choose to communicate your practice of medicine. Sounds simplistic, I am aware, but in reality is truth. As intelligent, experienced well trained physicians rising above the challenges inherent to health care reform can be easily surmounted. It provides a challenge to be sure, but as with any chess game; strategy can be developed and implemented to help you prevail.

 

To successfully navigate through Health Care Reform, the physician does not need to be well versed in ICD-9 or 10, GEM mapping, CPT codes or any other alpha- numerical language. And though knowledge of those would be beneficial, it is not mandatory for success. The physician simply needs to communicate their practice of medicine in a language that is understandable to non-clinical entities and can be translated into those alpha-numerical codes.

 

The American Medical Association (AMA) has provided a working list of necessary documentation components as follows;

 

  1. The medical record should be complete and legible.
  2. The documentation of each patient encounter should include: the date; the reason for the encounter; appropriate history and physical exam; review of lab, x-ray data and other ancillary services, where appropriate; assessment; and plan for care (including discharge plan, if appropriate).
  3.   Past and present diagnoses should be accessible to the treating and/or consulting physician.
  4.  The reasons for, and results of, x-rays, lab tests, and other ancillary services should be documented or included in the medical record.
  5. Relevant health risk factors should be identified.
  6. The patient’s progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance, should be documented.
  7. The written plan for care should include, when appropriate: treatments and medications, specifying frequency and dosage; referrals and consultations; patient/family education; and specific instructions for follow-up.
  8. The documentation should support the intensity of the patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making.
  9. All entries to the medical record should be dated and authenticated.
  10. The CPT®/ICD-9 codes reported on the health insurance claim form or billing statement should reflect the documentation in the medical record.

 

This list provides a good starting point, but in order to accurately capture severity of illness, intensity of service, medical necessity, quality of care and justify consumption of resources to appease third party payers, a higher degree of specificity is required. Clinical documentation that is accurate and explicit can help reduce queries, payment denials and negative profiling of you as a physician and help provide positive benchmarks accurately depicting the quality of patient care delivered.

 

Keeping the following points in mind will develop ideal documentation practices on a daily basis;

 

  • In the History & Physical list a diagnosis for every home medication.

 

  • The History & Physical must contain a Chief Complaint and encompassing history of present illness, vital to paving the way for establishment of medical necessity for admission and amount of work performed as part of the evaluation and management service.

 

  •  In the progress notes list a sign/symptom and provisional diagnosis for every lab or x-ray ordered. Also document a patient chief complaint for the day as well as interval History

 

  • Justify in the progress notes why the patient remains in the hospital today.

 

  • Daily progress notes must incorporate problems identified in the history and physical, treatment initiated patient’s response to treatment, major changes in the patient’s condition and action taken, status of unresolved problems, discharge planning and follow-up.

 

  • Daily progress notes do not have to reflect admitting information already stated previously in the History & Physical or progress notes.  (This can save some time)

 

  • Patients must meet continued stay criteria each day to remain in the hospital. From a clinically medical necessity perspective, daily progress notes should reflect the following of whether:

 

    1. The patient is stable, recovering or improving
    2. The patient is responding inadequately to therapy or has developed  a minor complication
    3. The patient is unstable or has developed a significant complication or significant new problem

 

 

The higher degree of specificity you choose the more advantageous to all. Health care oversight and regulation has become a permanent fixture but can be manipulated by following the “yellow brick road”. By adapting communication strategies which include specific, explicit documentation that accurately depict and communicate your practice of medicine you can tame the tempest.

 

Posted in: | Tags: physicians , nurses , health care reform , case managers , physician documentation , hospital , health care , HIMs , utilization review , revenue cycle professionals , Medicare , compliance , coders , ICD-10 , administration | Comments (0) | View Count: (3141)

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