Documentation Compliance 101: Protect Yourself by Tamala Bradham

In healthcare, after every patient encounter, test ordered and completed, and even phone calls should be documented in the patient’s medical chart. Here are five things you should know that they don’t teach you in school:

1) “What are you trying to hide?”
If your notes are not completed in a timely manner, then be prepared to answer “what are you trying to hide?” or “how many patients did you see that day? how could you remember what to write if you did your note a week later?” Any notes that are placed in the medical chart greater than 24 hours after the patient was seen/contact is subject to concern.

2) “Does it matter that my note was saved on the wrong date?”
Two things to know:
1) If the note is not there on the day of service, then the patient was not seen.
2) If you dropped charges and there is no documentation, then this is considered fraudulent billing and you could be subject to not only losing your license to practice but also significant fines.
Amend the note to the correct date of service! Or better yet, complete your note the day you saw your patient.

3) “What are the basic components that are needed in a clinical note?”
Every note completed should answer these six basic questions (and I give you the answers too):
1) When was this evaluation completed?
• Date and time services were rendered
2) Why are they here?
• History/Background
3) What did you do?
• Procedures performed
4) What did you find?
• Assessment/Interpretation
5) What should be done now?
• Recommendations/Plan
6) Who did this evaluation?
• Signature

4) “Why did you do that?”
Every procedure administered must be justified based on the ”History/Background” section. If audited, then you will need to answer “Why did you perform the tests/procedures administered?” If your answer is “This was how I was taught in graduate school” or “This is the clinic’s protocol”, then you may be in trouble. While standardization is necessary in complex organizations, performing unnecessary tests/procedures creates waste in the healthcare system and could be subject to fraudulent billings.

5) “Who is responsible for documentation and billings?”
While there may be protocols and procedures on how to complete documentation in your healthcare setting that are designed to comply with federal rules and regulations, insurance guidelines for reimbursement, and The Joint Commission guidelines, ultimately the person who saw the patient/client is responsible for what is documented and billed – not the place of business. Know the rules to protect yourself!

Documentation should not be considered additional work but an extension to your patient care activities. Know the rules, don’t over (or under) document, and get it done!


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