GUIDE TO CLINICAL DOCUMENTATION BY DEBRA SULLIVAN

Introduction I was honored when Andy McPhee of F. A. Davis approached me about writing a second edition of this book. I have always known that good documentation is important; however, over the past few years, I have developed an even greater appreciation for it. My renewed sense of the importance of documenting clinical encounters is related to my work as a nurse consultant within the Risk Management Department of a large health-care system. I have had the opportunity to read hundreds of charting entries. I’ve seen really good documentation and extremely poor documentation. I have a working theory that if there are any problems associated with a health-care encounter, the documentation about that encounter either will make those problems appear less significant or, as seems more often the case, will magnify the problems because of the lack of good documentation. Documentation used to be mostly a memory aid for the provider—a quick note of his or her thoughts about a patient’s presentation, a likely diagnosis, maybe a few words about the treatment plan. Over the past few decades, however, documentation has become a more complex task. This is due, in part, to the ever-increasing number of medications and treatment modalities available to health-care providers. Another reason is that patients live longer with a greater number of comorbid conditions, adding to the complexity of caring for them and reflecting that complexity when authoring a medical record. The fact that our society is so litigious certainly adds more weight to clinical documentation and puts a greater burden on the providers to capture their thoughts and actions for others to read and interpret years after the event. Dr. Mitchell Cohen wrote about this evolution of documentation in an article that appeared in Family Practice Management.* Dr. Cohen explains: From time to time I’ll stumble upon an old chart in my office that goes back 40 years. My predecessors charted office visits on sheets of lined manila card stock, which would suffice for at least 15 to 20 visits. Clearly, these charts were only intended for the physicians as a way to refresh their memory of what happened from one visit to the next. For example, the documentation for one visit read simply, “1/20/67: pharyngitis » penicillin.” These days chart notes are primarily not for the physician or patient, but for all the others who aren’t in the exam room and yet feel they have a stake in what takes place in this once confidential arena. To satisfy coders and insurers, my documentation for a 99213 sore throat visit must contain one to three elements of the history of present illness, a pertinent review of systems, six to eleven elements of the physical exam, and low-complexity medical decision-making. My malpractice carrier and my future defense attorney would also like me to explain my clinical rationale for why the patient has strep throat and not a retropharyngeal abscess or meningitis. A table with a McIsaac score calculating the likelihood that this patient does indeed have strep throat might be nice as well. If I prescribe a weak narcotic for a really nasty case of strep, the state medical board would be pleased if I addressed what other medication has been tried and whether the patient has any history of addiction. I’ll also need to document that I explained the proper use of any medications and the need for follow up if the patient doesn’t get better. When I’m finally done with my note, it looks like this: CC: Sore throat x 2d HPI: 17 y/o F with 2d h/o sore throat. Has an associated headache and fever to 101°. No significant cough. Patient has noticed some swollen lumps in neck. Having significant pain despite use of Tylenol, ibuprofen and salt water gargles. Social history: No history of substance abuse or addiction. ROS: Denies neck stiffness or back pain, no rash. No difficulty speaking. 2583_FM_ 11/28/11 10:29 AM Page xiii PE: VS: AF, VSS. Gen: Alert, pleasant female in NAD. HEENT: NC/AT, PERRLA, EOMI, TM clear b/l, OP notable for tonsillar enlargement with exudates. No asymmetry or uvular deviation present. Neck: + tender anterior cervical adenopathy, no nuchal rigidity or meningismus. CV: RRR S1/S2 without murmurs. C/L: CTAB. Abd: Soft, nondistended, nontender, no hepatosplenomegaly. McIsaac’s score = 4; Rapid strep: + A: Streptococcal pharyngitis P: 1. PenVK 500mg PO TID x 10 days. Discussed risks of medication including allergic reaction and complications of not taking full course of antibiotics including rheumatic fever and valvular heart disease. 2. Hydrocodone elixir QHS to help relieve pain particularly when trying to rest. Has already tried acetaminophen and NSAID and will continue salt water gargles. Follow up if no improvement in one week. Have discussed other potential diagnoses and reviewed warning signs of retropharyngeal abscess and meningitis. Patient agrees and understands plan. Like I said, “pharyngitis » penicillin.” (*Used with permission of the American Academy of Family Physicians) You may be feeling overwhelmed or a little intimidated by documentation at this point. Trust me, you’re not alone and not without help. The goal of this book is to give you a good foundation on which to build your skills. You will develop your own style of documentation as you learn more and more about medicine, about patients, and about the importance of communicating through the medical record. This book should be considered a “guide,” not a mandate. It is a basic road map to help you start on your journey. I hope you enjoy it along the way. Debbie Sullivan Phoenix, Arizona xiv | Introduction 2583_FM_ 11/28/11 10:29 AM Page xiv Chapter 1 Medicolegal Principles of Documentation OBJECTIVES • Discuss medical and legal considerations of documentation. • Identify groups of people who may access medical records. • Identify general principles of documentation. • Discuss medical billing and coding. • Identify benefits of using electronic medical records. • Identify challenges and barriers to using electronic medical records. • Define the terms electronic medical records, meaningful use, and interoperability. • Identify components of the Health Insurance Portability and Accountability Act. • Discuss principles of confidentiality. Medical Considerations of Documentation You might be asking, “Why a book on documentation?” Documentation is one of the most important skills a health-care provider can learn. You might feel tempted to focus considerably more time and energy on learning other skills, such as physical examination, suturing, or pharmacotherapeutics. These are essential skills, but documentation is likewise extremely important. State licensure laws and regulations, accrediting bodies, professional organizations, and federal reimbursement programs all require that health-care providers maintain a record for each of their patients. Good documentation is critical for many reasons. The medical record chronologically documents the care of the patient and is an important element in contributing to high-quality care. The medical record is the primary means of communication between members of the health-care team and facilitates continuity of care and communication among the professionals involved in a patient’s care. The patient’s medical record establishes your credibility as a health-care provider. It is important to remember that you are creating a record that other professionals will read; therefore, you should use professional language and include appropriate content. Other health-care providers will assume, rightly or wrongly, that you practice medicine much in the same manner in which you document. If your documentation is sloppy, full of errors, or incomplete, others will assume that is the way you practice. Conversely, thorough, legible, and complete documentation will infer that you provide care in the same way, thus establishing your credibility. Some excellent providers simply do not have good documentation skills. However, this is the exception rather than the rule. It is very difficult to persuade those who read sloppy documentation that the person who wrote that way can, and did, provide good care. Legal Considerations of Documentation All medical records are legal documents and are important for both the health-care provider and the patient, regardless of where the patient care takes place. The most important legal functions of medical records are to provide evidence that appropriate care was given and to document the patient’s response to 1 2583_Ch01_ 11/25/11 5:53 PM Page 1 that care. An often-quoted principle of documentation, which every health-care provider has probably heard, is that if it is not documented, it was not done. This is a fallacy because it is impossible to capture with documentation every nuance of a patientprovider encounter, and it is impossible to create a perfect record of every encounter. However, the principle behind the quote is important in a legal context; there is a considerable time lapse between when events occur (and are documented) and when litigation occurs. It may be anywhere from 2 to 7 years from the occurrence of an event until you are called to give a sworn account of the event. The medical record is usually the only detailed record of what actually occurred, and only what is written is considered to have occurred. You will not remember the details of an event that happened 6 years ago; your only memory aid will be the medical record. As a legal document, plaintiff attorneys, defense attorneys, malpractice carriers, jurors, judges, and most likely the patient will have access to the medical records you author. You should keep this in mind at all times when documenting. Other Purposes of Documentation Reviewers from various organizations can obtain access to a medical record for a variety of purposes. Representatives from insurance companies or state or federal payers can review the record for purposes of deciding on payment or looking for evidence of fraud and abuse. Peer review organizations might read the record to determine whether the care reflected in your documentation is consistent with the standard of care. Researchers often obtain access to medical records for purposes of conducting scientific studies. Although it is important to remember that these audiences may have access to your records, you should keep in mind that the primary audience of the medical records will be medical professionals involved in direct patient care. Throughout this book, you will analyze examples of documentation. You may also complete the worksheets, which will help you apply the information you have just read. The purpose of this book is to teach documentation skills and critical analysis of medical records. Our intent is not to instruct on the practice of medicine or to teach medical decision making.The content of a medical record—or learning what to document—varies greatly, depending on the patient’s presenting problem or condition. The principles of how to document and why documentation is important do not vary as much and thus are the focus throughout this book. General Principles of Documentation The Centers for Medicare and Medicaid Services (CMS) is one agency of the U.S. Department of Health and Human Services (HHS). As one of the nation’s largest payers for health-care services, CMS has established specific guidelines for documentation that we reference several times throughout this book. There are two sets of documentation guidelines currently in use: the 1995 and the 1997 guidelines. CMS published an evaluation and management guide in 2009; however, it was offered as a reference tool and did not replace the content found in the 1995 and 1997 guidelines.There are minor differences between the two guidelines, and it is recommended that health-care providers refer to the 1995 guidelines to identify those differences. Additional information may be found at . Both sets of guidelines recognize the following general principles of documentation: 1. The medical record should be complete and legible. 2. The documentation of each patient encounter should include the following: • Reason for the encounter and relevant history, physical examination findings, and diagnostic test results • Assessment, clinical impression, or diagnosis • Plan for care • Date and legible identity of the observer 3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. 4. Past and present diagnoses should be accessible to the treating and consulting providers. 5. Appropriate health risk factors should be identified. 6. The patient’s progress, response to and changes in treatment, and revision of diagnoses should be documented. 7. The Current Procedural Terminology (CPT) and International Classification of Diseases, 9th revision (ICD-9) codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical records. (More discussion of billing and coding is included later in this chapter.) There are other generally accepted principles of documentation, such as that each entry should include the date and time the record was created and should identify the person creating the record. In settings in which care is provided around the clock