By Hamilton Lempert, MD, Chief Medical Officer, Coding Policy
How are Clinicians Storytellers?
When you review a patient’s old records to find out what happened during their last hospitalization, you are grateful when you come across a well-written discharge summary that describes all the particulars of why the patient was there, what was done, the results and what the plan was going forward. Auditors are looking for this same information in each and every note when they review your charts.
In today’s age of electronic health records and notes becoming so long and all-inclusive, it has become even more important to paint a clear, comprehensive picture of what is going on with a patient on the day that you are seeing them. This may include an in-depth differential diagnosis or information about how each item on a patient’s problem list was addressed for that day. This is your Medical Decision Making, identifying what you are doing for the patient and why you are doing it.
The Key to Successful Coding? Tell a Story.
- Identify what has changed from a previous date of service, what results are back or what you are considering regarding treatment and follow up.
- Make sure the documentation for a particular date is from that particular date. Pulling forward information from previous notes without updating them for the current date of service may be considered immaterial documentation and may not be used to support the billed service. Much of our documentation could be viewed as repetitive from one patient to the next.
However, every patient is unique with their own story and their own journey through their condition. Being a good storyteller means creating a clear picture, through words, of each patient’s journey and what makes your thought process about their condition important. Yes, you may have documented the workup and thought process for chest pain many times, but think of a well-crafted operative note. Surgeons document what they did in the operating room (OR) in painstaking detail. We need to document what we did in our minds with just as much detail.
Lastly, on a completely different note, please document and sign your charts in a timely manner. Many payers require documentation and a signature at the time of service in order to bill for those services. Without timely documentation and signature, many charts become unbillable.
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