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!


Defining Quality by Tamala Bradham

“The definition of insanity is continuing to do the same thing over and over again and expecting a different result.”  Albert Einstein.

In one year, National Health Care in the Unites States grew 4% to $2.5 trillion (or $2,486 billion to be exact) in 2009 or $8,086 per person.  This accounts for 17.6% of the Gross Domestic Product consumed in the United States.  Medicare spending grew 7.9% to $502.3 billion and Medicaid grew 9% to $373.9 billion in 2009 (CMS, 2011).  The United States has the highest per capita health care costs of any industrialized nation! Increasing costs are reducing access to care and constitute an ever heavier burden on employers and consumers.  Yet as much as 20 to 30 percent of these costs may be unnecessary, or even counterproductive, to improved health (Wennberg, Brownless, Fisher, Skinner, & Weinstein, 2008).

Addressing these unwanted costs is essential in the survival of providing quality health care.  Some argue that implementing quality management programs is costly.  Others would say that poor quality is costly.  There are many definitions and ideas of quality.

According to my old, reliable Webster’s New World Dictionary (Neufeldt & Guralnik, 1988), quality means “any of the features that make something what it is…the degree of excellence which a thing possesses”.

The Centers for Medicare and Medicaid services (CMS, 2008) defines quality as “how well the health plan keeps its members healthy or treats them when they are sick. Good quality health care means doing the right thing at the right time, in the right way, for the right person—and getting the best possible results.”

Taking this a step further, I wanted to define quality of care.

Interestingly, Wikipedia does not define “quality of care”.

So, lets turn to the experts who wrote the infamous “Crossing the quality chasm: A new health system for the 21st century”.  The Institute of Medicine (IOM) states “quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 21).  IOM developed six specific aims for improvement which consist of the following:
• Safe: avoiding injuries to patients from the care that is intended to help them.
• Effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit.
• Patient-centered: providing care that is respectful of and responsive to ­individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.
• Timely: reducing waits and sometimes harmful delays for both those who receive and those who give care.
• Efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy.
• Equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (IOM, 2001).

To further strengthen this definition, the World Health Organization (2006) adopted the above six aims as their working definition of quality of care.

For me, when I think of quality of care, I need a simple definition, sort of like a mission statement – short, succinct, and powerful!  So I turn to Martin Van Buren who said “It is easier to do the job right than explain why you didn’t.”

Portions of this blog came from an article previously published.
Bradham, T.S. (2011, Invited). Quality 101: What every audiologist and speech-language pathologist should know but was afraid to ask. Perspectives in Hearing and Hearing Disorders in Childhood Deafness, ASHA, 4-7.