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How to meet (and exceed!) documentation requirements

Staff Development Weekly: Insight on Evidence-Based Practice in Education, August 14, 2007

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To reduce errors in medical billing, staff members must not claim ignorance of rules and regulations that they are professionally required to know, and medical records must clearly support the performance of services rendered, as well as their medical necessity, so that genuine mistakes become more uncommon. Therefore, what changes can facilities implement to improve their current system and thereby restore public trust in medical billing accuracy?

Consider the following options at your hospital:

• Follow currently established rules. Do your staff members know the rules and follow them? Do they fail to discipline certain physicians or perhaps rationalize their own lenient behavior because everyone else has always behaved similarly in the past? If so, perhaps a review of the rules is in order.
• Encourage legibility. Both the CMS and The Joint Commission require legible records and state that handwriting quality affects patient safety and continuity of care. Two non-physician staff members should be able to read every note or order written by a physician. The medical executive committee is responsible for monitoring and reporting compliance with this fundamental requirement.
• Establish the timeliness and quality of the admission history and physical (H&P) as a core measure for physician performance monitoring. The physician admission H&P is the foundation of a patient's hospital care. Not only does an untimely or incomplete H&P reflect poorly upon all staff members, but it can also serve as useful fodder for opposing counsel in the event of a lawsuit. If a physician performs the H&P unprofessionally, managers may have a difficult time convincing insurance companies that care is medically necessary, and coders may encounter problems trying to accurately represent a patient's severity of illness.

To get more information, go to Medical Records Briefing (MRB). For the cost of just three stories, you can get the entire August issue of MRB. Click here to choose between the PDF and HTML versions for just $30. Subscribers to the online version of MRB have free access to this article. Subscribers to the print newsletter can find this article in their August issue.

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