23 Tips on Improving Your Documentation

  Documentation is an intrinsic component in every patient encounter. With regulatory organizations closely monitoring activities, patient quality of care at stake, and the financial success of a wound clinic are all dependent on the quality of documentation.

  The following are tips and takeaways are meant to improve the clinic’s practices in the area of documentation.

  1. The financial success of a facility depends upon the completeness of the process.

  2. The major factor affecting the quality of an organization’s data (and therefore its revenue stream) is the accuracy of documentation.

  3. 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.

  4. Documentation is essential to meet the changing demands of regulatory bodies such as The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), The Office of the Inspector General (OIG), and CMS.

  5. Documentation must validate the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided.

  6. The medical record should be complete and legible.

  7. The documentation of each patient encounter should include the reason for the encounter and relevant history, physical examination finding and test results, assessment, clinical impression or diagnosis, plan for care, and date and legible identity of the observer.

  8. The patient’s progress, as well as response to and changes in treatment must be documented.

  9. The billing codes reported on the health insurance claim form should be supported by the documentation in the medical record.

  10. Accepted methods for correcting errors and amending records should be used.

  11. Electronic records now support electronic signatures, which append a statement such as electronically signed by after the clinician enters an assigned security code.

  12. Conduct that is not acceptable includes allowing patterns of retrospective documentation to increase reimbursement, misusing sensitive data or violating the privacy of an individual.

  13. While the clinic charges might be calculated using a scoring tool, the tool itself is not sufficient documentation of the services provided. The medical chart must still contain all the elements upon which the score is based.

  14. The standard unit for measurement is in centimeters.

  15. The wound bed and the periwound skin can be described.

  16. Granulation, slough, eschar, and epithelization can be described and/or assessed in percentage of wound surface area.

  17. Drainage can be classified by amount and character.

  18. Pain should be assessed.

  19. Dressing products should be documented.

  20. Documentation includes, the plans for the frequency of their change and the duration of these orders.

  21. Third party payers often have specific documentation requirements for the provision of medical equipment or dressing products.

  22. Healthcare providers are expected to participate in continuous quality improvement. Medical records provide important information about practice patterns on groups of patients, not just one individual.

  23. Don’t Get Frustrated. Compared to other US industries, the healthcare system has been slow to effectively incorporate information technology into the work environment.