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3 Clinical Documentation Best Practices for Every Doctor

Clinical documentation is complicated and getting more so.

Some of the complexity has to do with EHRs, to which physicians are still adapting. Much of it relates to Medicare, which has a number of goals related to the medical record. Dr. Lorena Chicoye, corporate medical director of managed care at Baptist Health South Florida, discussed this at length in an H&HN article late last year. Medicare, she said, wants to ensure that physician’s thought processes are correct, that they are following through on those processes, and that the documentation they create support what they are being reimbursed for. A tall order, to be sure.

These practice guidelines are crucial for ensuring that all information exchanged during a patient-physicians interaction are recorded and added to the patient notes. The American Academy of Professional Coders lists a handful of useful approaches including

  • Make sure health records only contain accurate information
  • Encourage patients to routinely read over their entire health care record
  • Medical staff should consider health record documentation as part of core competencies

Some good work is being done in the US and elsewhere designed to help clinicians improve their documentation, both to meet CMS regulations and prepare for next year’s ICD-10 changeover. Below are three best practices all physicians should consider implementing.

  1. Ensure that the six Cs are always included in the patient record: cause of the symptoms, chronic conditions that could impact patient care, clinical significance of abnormal test results, check laterality (note right or left side), clarity (can the reader follow your ideas, and current state (is the patient’s problem list and medication list current?).
  2. Designate someone in your practice to educate themselves on the importance of accurate clinical documentation and how accuracy can impact both patients and the practice. In addition to becoming the go-to person for documentation clarification, this individual can work with the physicians to create measurable goals for documentation improvement.
  3. Conduct periodic documentation reviews, making sure everyone in the practice understands this is being done to identify knowledge gaps, not to punish individuals.

Because clinical documentation improvement programs can be controversial, the person in charge of the program must be considered a peer by the physicians the program is targeting. “By using peers to provide guidance on clinical documentation, I established a higher level of credibility and respect, and I minimized the physician resistance I sometimes encounter as part of a traditional CDI program,” writes Chicoye. Sound advice for those striving to capture the type of complete clinical data practitioners need to be appropriately reimbursed and prepared for documentation-related questions from patients, auditors, and attorneys.

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