Note to Self: Document Wisely

The Hospitalist. 2008 July;2008(07):

July 1, 2008|The Hospitalist

One patient was as “fat as a whale,” according to his medical record. A patient who fell out of bed at night had “a nocturnal misadventure,” according to his chart, which provided no further information. Another medical record stated that a patient had been seen without the physician reviewing previous documentation. Yet another chart says the doctor referred the patient to a physician whose “credentials he was unsure of.”

Whether humorous or serious, medical records all too often include inappropriate information. While some of it may seem merely tasteless or silly, inappropriate remarks can cause serious problems—medical, legal, regulatory, and financial.

Because records are critical in so many areas of medical practice, hospitalists need to work harder to ensure they are accurate and appropriate. Experts say there should be more training in documentation.

“Doctors are trained to think about clinical and legal issues in documentation, but far less about the regulatory and billing aspects,” says David Grace, MD, area medical officer for The Schumacher Group, Hospital Medicine Division, in Lafayette, La., who saw the records of the obese patient and the one who fell at night.

As area medical officer, Dr. Grace reviews records and is developing a fellowship for Schumacher’s hospitalists in which documentation will be taught early on. “You have to teach doctors how to be hospitalists, and proper documentation is critical,” he says.

Patrick O’Rourke, an attorney for the University of Colorado, Denver, and legal columnist for The Hospitalist, also believes doctors need more training in documentation. He works with them on that in order to help them “stay out of court.”

Document for Billing, Compliance

One key area is documenting patients’ conditions thoroughly upon admission so reimbursement is not denied because it is assumed a condition developed during hospitalization.

For example, document conditions like pressure ulcers that could develop into bedsores or urinary infections that could be traced to a catheter.

“There’s tension between documenting to support billing/coding and for the best medical care because it can make it less clear what the most pressing medical problem is; both are important,” says John Nelson, MD, a partner in Nelson Flores Associates, a hospitalist consulting firm.

Dr. Nelson, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., and a co-founder and past president of SHM, says doctors have to find the balance.

“Just documenting for one would be like staring at the speedometer and gas gauge while you’re driving,” he cautions. “You won’t speed or run out of gas, but you may hit a wall.”

Dr. Nelson believes templates can be helpful, particularly for coding and billing. He urges physicians to always think about what they need to report that is not in the template.

Dr. Li’s group takes very seriously the need to use templates as guidelines only. “For example, the detail of the history and present illness is not templated,” he says. “The patient’s story, when the problem started, what made it better, worse, etc. must be written out.”

There are things physicians don’t need to write out, he says. For example, using a pain scale is effective on a template and the assessment of pain and the documentation of its treatment is very important to the Joint Commission, he says.

“A template is a tool to help you document more efficiently,” Dr. Li says. “The point is to do whatever you need to do to provide for other providers, legal documentation, and billing.”—KF

The Courtroom

O’Rourke, who has worked on medical malpractice cases for his university’s Health Sciences Center and in private practice for 11 years, says the most common inappropriate wording he sees is back-handed denigration.