Properly documenting patient’s medical records has always been important, but never more than now, given today's health care landscape where the government ties reimbursement to the quality of the medical record.

"Medical reimbursement is reflective of what you document, not what you do," says David Thompson, MD CHC FACEP, chief medical information officer, SCP. "I can take care of a patient with a wrist fracture, pneumonia, or a myocardial infarction, but if there is no documentation, there is no reimbursement."

For that reason and more, Dr. Thompson encourages providers to "think with your ink" and put good documentation practices into place.

Four Reasons to Document Properly

Dr. Thompson cites four reasons why it’s vital to properly document patients’ medical records.

Improve Patient Care outline

1. Communicates with other health care personnel

Documentation communicates the quality of clinical care that providers are delivering to patients and serves as a means to facilitate the continuum of care, from EM to HM and beyond.

2. Reduces risk management exposure

Documentation mitigates risks and reduces the chance of malpractice. A well-documented record can help alleviate liability concerns in the event of a claim.

3. Records CMS Hospital Quality Indicators and PQRS Measures

Documentation captures value-based purchasing metrics that, increasingly, the government is asking hospitals to provide. These include Hospital Quality Indicators and PQRS measures.

4. Ensures appropriate reimbursement

A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any “hassles” associated with claims processing, and ensure appropriate reimbursement.

"Ninety-five percent of ensuring appropriate reimbursement is just good documentation practices that every one of our doctors knows," Dr. Thompson says. "The other five percent consists of learning the rules provided by the federal government and other organizations that we need to know from a documentation compliance standpoint, so that we are reimbursed correctly."

In addition to these four, other reasons why proper medical record documentation is important include:

  • It tells the patient's "story": the presenting problem and the treatment received;
  • Helps to plan and evaluate a patient’s treatment;
  • Creates a permanent record for the patient’s future care;
  • Builds a database to evaluate the effectiveness of treatment that may be useful for research and education.

Documentation FAQ Weekly Emails

As of August, Dr. Thompson began sending weekly FAQ emails on clinical documentation improvement to all SCP HM and EM providers.

Here is one example:

Emergency Medicine Documentation Tips & FAQs:

Question: What does "Four on the Floor" mean?

Answer:

For car buffs, the phrase "four on the floor" means a four-speed manual transmission mounted beside the driver on the floor of the vehicle. More recently, it has become a term for a type of rhythm pattern used in disco and electronic music.

However, for Emergency Medicine, this phrase is a reminder that four (4) elements in the history of present illness (HPI) are required to get full coding credit for your evaluation and management services for complex patients. This describes most patients requiring admission or transfer and other patients requiring a high level of medical decision-making.

The possible elements that you can document in your HPI are:

  • Location;
  • Quality;
  • Severity;
  • Duration;
  • Timing;
  • Context;
  • Modifying factors; and
  • Associated signs and symptoms.

(This list comes from Medicare’s 1995 and 1997 documentation guidelines.)

“The goal behind the email campaign is to provide clear, concise, easy to digest information for providers to consume," he says. "Good clinical documentation is part of the core responsibility of every doctor. It's my hope these emails will help foster a culture of excellence and mindfulness that leads to even better patient care.”

Conclusion

Clear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping health care providers evaluate and plan the patient’s treatment and maintain the continuum of care.

Take Dr. Thompson’s advice and “think with your ink.” Make your clinical documentation complete, accurate, and precise.