Home Uncategorized Charting 101: making sure your documentation is on time and legible

Charting 101: making sure your documentation is on time and legible

March 2008

Published in the March 2008 issue of Today’s Hospitalist

HOSPITALISTS HAVE GOTTEN to be pretty savvy when documenting different levels of inpatient visits and physician decision-making. But when it comes to the basics of good charting, such as the need for timely and legible documentation, they sometimes fall short.

Physicians who don’t abide by those basic rules are setting themselves up to be shortchanged on reimbursement. They may also find themselves in hot water because of hospital regulations or medical liability concerns.

Here’s a look at charting basics that can help you maximize reimbursement and steer clear of common pitfalls.

RULE #1: Get it done on time
Physicians should aim to complete charts immediately after treatment when details are still fresh.

Most hospitals set time limits for when documentation is due: within 24 hours for admitting notes, 48 hours for surgical procedures and 15 days after discharge for completing the record. Payers often request records to substantiate a payment, so any lag in documentation could result in non-payment.

RULE #2: Make it legible
The legibility of your documentation can have a huge impact on how much you’re paid. That’s because any portion of a record that can’t be read could be disregarded and result in down-coding, non-payment or a refund request.

Legibility is also a key concern when it comes to your own risk of liability. If reviewers, state board investigators or a malpractice jury can’t read your records, they may conclude that your treatment deviated from the standard of care.

If the next treating physician cannot decipher your writing, that could affect patient care. (Failing to record complete treatment details can produce the same result.) And a lack of legibility could affect which diagnoses are coded: PUD or PVD? Peptic ulcer disease or peripheral vascular disease?

RULE #3: Get your abbreviations straight
Abbreviations can pose another type of pitfall when you deviate from standard usage. Imagine a coder trying to figure out if “ARF” means acute renal failure or acute respiratory failure. Or if “PE” stands for pleural effusion, pulmonary edema or pulmonary emboli.

To avoid such confusion, be sure your group establishes a list of abbreviations that everyone agrees to use. That way, your documentation will support the diagnosis code.

RULE #4: Beware of “charting by exception”
An electronic medical record (EMR) can solve legibility problems and facilitate documentation. But when using an EMR, physicians need to beware of a common practice known as “charting by exception.”

EMRs are usually set up to record normal findings, with physicians indicating findings that are abnormal. One result is that physicians often rush through their EMR charting and don’t check any abnormal findings that apply.

When reviewing documentation, for instance, I might find a chart for a patient who’s been admitted with chest pain as the chief complaint. But that patient’s cardiac review of symptoms will read “normal” or “negative” because the physician didn’t change the “normal” default.

Another caveat of using EMRs: Be sure to chart only those services you’ve actually performed. EMRs make it very easy to document a complete physical, review of systems, and family and social history on every patient “whether or not a comprehensive review actually was performed or warranted by medical necessity. Failing to accurately document the level of service performed could lead to all of your records being questioned.

RULE #5: Don’t leave anything out
On the other end of the spectrum is another pitfall that’s just as serious: not documenting all the services you provide. If it’s not written in the chart, you have
no evidence that it was done!

You need to document every prescription or professional service, no matter how informal or insignificant “even for a friend or a fellow staff member.

RULE #6: Be careful when making changes
Keep in mind that the medical record is a legal document and should never be altered. If you need to change or add to a patient record, write an addendum with the date of the revision.

Never write over an original entry or make it unreadable. Instead, if there’s an error in a chart, draw a single line through the portion you’re correcting, keeping the original entry legible.

Sign and date the deletion, and state the reason for making the correction above or in the margin. Document the correct information on the next line or space with the current date and time, referring back to the original entry.

When correcting electronic records, follow the same principles: Track both the original entry and the correction with the current date, time and reason for the change. Any corrected record you submit must make clear the specific change made, the date of the change and the identity of the person making the entry.

Complete and accurate medical records improve the quality and efficiency of medical care, and lower costs. Paying attention to charting basics not only protects your patients’ interests, but your own.

Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker@hotmail.com. We’ll try to answer your questions in a future issue of Today’s Hospitalist.