Revised 8/20/21

Properly documenting patient’s medical records has always been important, but never more than now, given today's healthcare landscape where the government ties reimbursement to the quality of the medical record.

"Medical reimbursement is reflective of what you document, not just what you do," says Dr. David Schillinger, SCP Health's Chief Medical Officer. "We can take care of a patient with a wrist fracture, 

For that reason and more, Dr. Schillinger encourages providers to "put thoughts to paper” and put good documentation practices into place.

Four Reasons to Document Medical Records Properly

Follow along with four reasons why it’s vital to properly document patients’ medical records.

1. Communicates with other health care personnel

Documentation communicates the what, why, and how of clinical care delivered to patients. These records allow other clinicians to understand the patient's history so they can continue to provide the best possible treatment for each individual. 

Proper documentation also serves as a means to facilitate patient navigation and coordination along the continuum of care, from EM to HM and transitioning into the post-acute care setting.

2. Reduces risk management exposure

Thorough and accurate documentation mitigates risks and reduces the chance of a successful malpractice claim. A well-documented record serves as evidence of treatment and care, helping to alleviate liability concerns in the event of a claim.  It is unlikely you will remember details of a particular case several years later when you are in the middle of a professional liability claim.  Your documentation will be the tool you rely on in this situation.

3. Records CMS Hospital Quality Indicators and PQRS Measures

Documentation captures value-based care metrics that, increasingly, the government is asking hospitals to provide. These include Hospital Quality Indicators and MIPS measures.

4. Ensures appropriate reimbursement

A well-documented medical record can facilitate effective revenue cycle processes, expedite payment, reduce any "hassles" associated with claims processing, and ensure appropriate reimbursement.

"Ninety-five percent of ensuring appropriate reimbursement is just good documentation practices that most our clinicians know," Dr. Schillinger says. "The other five percent consists of learning the rules provided by the federal government and other organizations that we need to know from a documentation compliance standpoint so that we are reimbursed correctly."

Other reasons why proper medical record documentation is important include:

  • Tells the patient's "story," the presenting problem and the treatment received
  • Helps to plan and evaluate a patient’s treatment
  • Creates a permanent record for the patient’s future care

Improving Provider Documentation

It's one thing to know the reasons documentation is important, and it's another to ensure that it's done correctly. There are several ways to help clinicians improve their documentation skills. . 

1. Standardization

Use industry standards to create note-taking guidelines that work for your practice. Make sure that clinicians are focusing on clear and concise communications that will benefit other readers of the medical records. 

2. Regular Review

Review prior records and encounters; with current EMR's, this is often a simple process.  Some health records even allow you to view records from other facilities on the same system. 

3. Peer Support

No one understands the ins and outs of documentation quite like other clinicians. Pinpoint excellent documenters as go-to experts for questions and concerns. Peer-to-peer support of documentation will increase standardization and productivity.

4. Continued Education

Clinicians never stop learning as they practice and that should be true when it comes to documentation as well. Regular emails with tips and ideas for improvement helps keep clinicians up to date on best practices and increase documentation compliance.

Conclusion

Clear and concise medical record documentation is critical to providing patients with quality care, ensuring accurate and timely payment for the services furnished, mitigating malpractice risks, and helping healthcare providers evaluate and plan the patient's treatment and maintain the continuum of care.

Take Dr. Schillinger's advice and "put thoughts to paper." Make your clinical documentation complete, accurate, and precise.