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Topic: Consider these methods to achieve record completion while patients are in-house

HIM Connection, May 28, 2007

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Organizations have used several methods to achieve record completion while patients are in-house. Some of the following options are equally as effective for multiple encounters in active outpatient settings. These options also are effective in rehabilitative settings.

1. A designated (non-HIM) record-review team performs concurrent record analysis during concurrent record review

Pro: The reviewers are already looking at the documentation and can assess whether it is truly complete and adequate.

Con: Depending on the review approach, you may not review all records. These reviewers, typically clinicians, may find tagging incomplete documentation more appropriate for clerical staff.

2. Staff perform concurrent record analysis during utilization and case-management reviews

Pro: These individuals are most in need of complete documentation and have the ability to encourage additional details often missing from physician documentation.

Con: Depending on the utilization review/case-management approach, staff may not review all records. These reviewers may find tagging incomplete documentation more appropriate for clerical staff and therefore fail to perform the function.

3. Patient-care personnel identify documentation deficiencies and tag them as they compile the patient record

Pro: The patient-care support staff or unit secretaries frequently refer to all patient records on the floor. They can easily determine whether a document has blanks or whether a verbal or telephone order lacks a physician signature. Tagging this deficiency is within their skill set. These staff members are more likely to see the physician and remind him or her to complete the record.

Con: Many organizations have decreased the support staffing in patient-care areas. Because HIM departments distribute many reports 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

Pro: The HIM staff's purpose is to complete records, and therefore, they believe tagging is an appropriate assignment.

Con: 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 adapted from the HCPro book More With Less by Rose Dunn, RHIA, MBA, CPA, FACHE, FHFMA. For more information on this book, click here.

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