Documentation is expected to be generated at the time of
service or short thereafter. What is
“shortly thereafter”? This varies
according to both the environment and the practitioner. Initial documentation is completed twenty
four to forty eight hours following the rendered services. Unusual circumstances may preclude this
anticipated documentation. Examples of
this are error correction or additional information to be recorded in the
initial time period that was overlooked.
All medical entries must be signed by the person who performed the
particular service.
An absolute...
The medical
record cannot be alter, but as alluded to above, there are times when the
record must be amended. The following are
guidelines to amend a medical record appropriately:
·
Reference
date that you are amending the record
·
Write
the details of the amended information
·
Document
that this is an addendum to the medical record
·
Include
the date of serve that you are referencing for amendment
·
End
with your signature and credentials
A
common error
Every service record should be
separately identifiable. Delayed written
explanation is not given as much credence as the one written at the time that
the service is provided. Addenda to the
medical record should not be a routine.
Documentation should be such that an independent coder/reviewer will be
able to identify the level or type of service provided. It is not sufficient to provide written
addenda on the billing records alone. It
must be included in the original medical record.
A
common Adage sums up most record deficits:
“if it isn’t documented, it wasn’t
done.” It can be coded and billed
for, but chances are it will not be reimbursed.
Legibility
Legibility is a necessity that is often overlooked. Another person reading the documentation must
be able to determine what service were provided and for what reason they were
provided. This is not only a billing
issue, but a patient care issue. The
history of care is important in determining the future care plan and the
ultimate successful treatment outcome.
Cloning
Template
charting is not the best use of efficient charting. In fact medical record “cloning” is frowned
upon. The determination of a cloned
record is a possibility when each entry in the medical record is worded exactly
alike or similar to the previous chart entries.
Cloned records do not meet the medical necessity requirements for
coverage of services to the lack on specific, individual information. Documentation must be specific to the patient
and his/her situation at the time of the service.
Templates
are useful, but they must represent what actually took place and not something
that the provider normally does.
Additionally, pre-charting a planned action is dangerous for patient
care and leads to questions of the over-all patient care.
Several
other common errors are found during medical record review. The number of service units is sometimes
overlooked. More often it is noted that
the units for a particular service are time based. These type of services must correspond to the
documentation of the time spent with the client when rendering the
service. A reasonable period of time
must be recommended and documented. If
the service requires an extended period of time it is essential that this is
clearly documented within the medical record.
Occasionally the order for service does not match the service provided
which may lead to larger problems when the records is reviewed. To ensure medical necessity of the medical
treatment plan, all documentation must clearly demonstrate the treatment and
the treatment outcome.
In summary
These are
just some of the common documentation oversights found during medical record
audits. Ultimately it is attention to
detail in a timely manner that will allow the medic al provider to effectively
communicate the care and treatment outcome of each individual.
