Documentation:The 30,000-Foot View
May 12, 2008
Caroline Fife, MD, FAAFP, CWS
Documentation is an intrinsic component of every patient encounter. The financial success of a facility depends upon the completeness of the process. The major factor affecting the quality of an organization’s data (and therefore its revenue stream) is the accuracy of documentation. If you are not already convinced of the importance of accuracy in documentation, a study by the Centers for Medicare & Medicaid Services (CMS) found that of all of the improper Medicare benefit payments made during 2001, 43% were due to documentation errors. It is well known that patient quality of care is also related to quality of documentation. Furthermore, documentation is essential to meet the changing demands of regulatory bodies such as the The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Office of the Inspector General (OIG), and CMS.
The What and Why of the Medical Record
In the 19th century, the medical record was a sort of personalized lab notebook in which clinicians recorded their observations. In the 21st century, the medical record has many functions, including, serving as a basis for planning and documenting patient care, communicating among numerous health professionals, and protecting the legal interests of the patient and healthcare providers. The medical record may supply information for internal hospital auditing and quality assurance, documenting compliance with governmental regulations, and provide data for medical research. It is also a means of determining the billed revenue for physicians and hospitals. Thus, documentation must validate the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided. What is more interesting about today’s medical records is that they serve as a way of tracking the process of care not just for an individual patient, but for groups of patients in the form of benchmarking and clinical research.
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