Cath Lab Digest

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.

General Principles of Documentation
This brief article cannot serve as an exhaustive resource on the legal or medical aspects of documentation. However, there are some basic principles. The medical record should be complete and legible. The documentation of each patient encounter should include the reason for the encounter and relevant history, physical examination findings and test results, assessment, clinical impression or diagnosis, plan for care, and date and legible identity of the observer. The patient's progress, as well as response to and changes in treatment must be documented. The billing codes reported on the health insurance claim form should be supported by the documentation in the medical record. Accepted methods for correcting errors and amending records should be used. While signatures are handwritten in paper documents, electronic records now support electronic signatures which append a statement such as electronically signed by after the clinician enters an assigned security code. Ethical principles pertaining to medical records are available from The American Health Information Management Association (AHIMA). Conduct which is not acceptable includes allowing patterns of retrospective documentation to increase reimbursement, misusing sensitive data or violating the privacy of an individual.

Physician Documentation
Evaluation and Management codes (E/M codes) used for physician billing are copyrighted and maintained by the American Medical Association. The payment system uses two sets of codes: ICD9 is used to identify the patient’s pathology (diagnosis) and support medical necessity; the Common Procedural Terminology (CPT) is used to code the physician’s treatment of that pathology (ie, the services provided). Payment is associated with different degrees of complexity of care based on key components. Each key component has four levels of difficulty. So, a physician using the 1997 Medicare Documentation Guidelines has 42 choices to consider, ultimately representing 6,144 possible combinations in order to select the correct E/M code (May 25, 2000 “Statement to the Health Task Force Committee on the Budget, United States House of Representatives, Medicare Regulatory Burden Imposed on Physicians,” www.acponline.org/hpp/hbstmt.htm). Electronic medical records systems, which automate this process, are becoming increasingly popular.