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Complete medical records while patients are in house

HIM Connection, March 28, 2006

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With physician reimbursement declining, regulations increasing, and paperwork quadrupling, it's no wonder physicians miss documents and have incomplete records. This week, HIM Connection focuses on helping doctors-which simultaneously benefits the HIM department-deal with concurrent record analysis in order to complete records at or near the time of discharge.

Organizations can use several methods to achieve record completion while patients are in house. Consider the following options, which are equally as effective in active outpatient settings where patients have multiple encounters or rehabilitative settings:

1. Concurrent record analysis occurs during record review by the record-review team.
   Plus: The reviewers are already looking at the documentation and at this time they can assess whether the documentation is truly complete and adequate for other caregivers.
   Minus: Depending on the review approach, not all records may be reviewed. These reviewers, typically clinicians, may find the tagging of incomplete documentation more appropriate for clerical staff.

2. Concurrent record analysis occurs during utilization and case-management reviews by staff who perform these functions.
   Plus: These individuals are most in need of complete documentation and have the ability to encourage additional details often missing from physician documentation.
   Minus: Depending on the utilization review/case-management approach, not all records may be reviewed. These reviewers may find tagging incomplete documentation more appropriate for clerical staff.

3. Patient-care personnel identify documentation deficiencies and tag them as they compile the patient record.
   Plus: The patient care support staff or unit secretaries are in and out of all patient records on the floor and can see whether a document has blanks or a verbal or telephone order lacks a physician signature. Tagging this deficiency is within their skill set. These staff are more likely to see the physicians and remind them to complete their records.
   Minus: Many organizations have decreased support staffing in patient-care areas. Because many reports are now distributed through a network printing system, support staff have absorbed much of the charting efforts performed by HIM and ancillary services.

4. Designated HIM staff review patient records daily for documentation deficiencies and tag them accordingly.
   Plus: The HIM staff's purpose is to complete records, and therefore, they believe tagging is an appropriate assignment.
   Minus: The HIM staff will not have the opportunity to remind physicians because the presence of HIM staff in any patient-care area will be transient.

Editor's Note: This article was excerpted from HCPro, Inc.'s book More with Less: Best Practices for HIM Directors, written by Rose T. Dunn, RHIA, CPA, FACHE, FHFMA. For more information or to order go to www.hcmarketplace.com or call 877/727-1728.

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