Document the Work You Do!

By Kathy Arner, RPN, RHIT, CCS, CPC, CPMA, MCS
AHIMA approved ICD-10 trainer
Coding and Compliance Auditor III for Quality and Safety

Working in the Health Information field for over 40 years, documentation by the physicians has always been an issue. They just need to document the work they do. If the physician wants to do work and not get paid for the work, he/she is doing that is their choice. Quite frankly, doing shadow audits with physicians, they are doing the work, but just not putting it down on paper or in the electronic health record.

By now the physicians have heard it all. Having CDI is a good thing and don’t get me wrong, but documentation for patient care should begin while they are in training to be physicians. You can’t wait until they are on the floors doing work to begin training. CDI just re-enforces what they should be doing all along.

Having done shadow audits with physicians, they go in and speak with the patient and the patient is telling them all the review of systems, physician examines the patient and does his/her medical decision making, but then fails to write down all the review of systems. This is so important and will drop your evaluation and management code, again the work is done and the physician is not giving credit for the work that is done.

It just seems so simple to document what work has been done. Maybe you have seen the patient over and over on an outpatient basis, but each time they enter the office, it’s a new encounter. Everything done before does not count and what you are doing on this visit is separate from anything that was done before. Follow -up has been written many times, but follow-up to what? The reader has no idea what your following up on.

Physicians don’t have to write lengthy notes to get credit for what they are doing, they just need to be accurate and descriptive and as detailed as possible. Example: when writing pneumonia if known write the type of pneumonia. “Tell a story of the visit.”

The progress notes are not only for the Physician to get paid, but for billing purposes, coding diagnosis and procedures, codes can be used for getting more equipment, International Stats, legal issue and just getting your staff paid, etc.

All diagnosis and not just what the patient came for effect the care of the patient that day should be documented as an assessment. If you have a medicine that was reviewed for a condition that also needs to be documented.

When a patient comes for a clinic visit, the first thing a Dr. does when entering the room is assess the patient, document what you see. For example, a patient came to his Primary Care Dr after being discharged for a Below Knee Amputation, the Dr. never documented the BKA. Don’t you feel this would affect the care that was given to the patient that day. I’m sure that patient had some degree of difficulty arriving and being seen that day for his/her appointment. What a missed opportunity.

Chronic conditions such as SLE should be documented every time, if care is given as it affects the patient care.

We all agree that Physicians/Providers have a lot to remember, but by documenting all that you do for the patient, helps all of us to make sure the patient receives good care.

Take away:

• You already do the work, take credit for it by documenting. Provide documentation that supports the diagnosis or procedure billed
• When writing follow up (f/u) give the reason for follow up. Ex: Diabetic Neuropathy
• All encounter progress notes must have a patient name, date, time, provider signature and credential, no rubber stamps
• Remember chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition, document a short evaluation of the disease.
• Only use “History of” if no further treatment is given to the disease.
• The note must be able to stand alone and must be legible.
• Be specific with the Diagnosis – Ex: Acute Renal Failure vs Renal Failure.
• “Tell a story of the patient visit” list correctly, first the diagnosis for why the patient is being seen followed by all secondary diagnosis that are treated.