Documentation
Emergency
departments spend their fair share of time under the microscope
by managers, government agencies and payer groups. We all know
firsthand of JCAHO, Medicare and Medicaid's precise attention
to documentation. Their mantra is: It didn't happen if it's not
documented. It didn't happen if you can't read it.
Physicians' documentation is coming under
particular scrutiny. This is caused by both medical/legal and
reimbursement issues. Our litigious society has caused us to document
anything and everything that was done, not done or even thought
about. As hospitals fight to remain financially viable, lost revenue
from inadequate documentation is unacceptable. We must document
thoroughly to protect ourselves and to be fairly compensated for
what we do.
Below are some tips on how to help avoid
documentation problems:
1. Signatures: These are an extremely
important part of the chart. They must be legible so that billing
clerks and others who review the chart can accurately identify
the physician providing the care. Make sure the signatures are
clearly legible. If not, then also print the physician's name.
2. Dictation: One of the easiest ways
to address poor documentation is to dictate the medical record.
Dictation when available should always be used. Dictated charts
provide a much more detailed and legible medical record. Quite
frankly, with dictation you include much more detail and provide
a more thorough report of the patient visit.
This increased detail helps defend the
provider if the care given is questioned at a later date, as well
as supporting the charges for the services.
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