How to overcome the risks of poor document management workflow?

Medical documentation is digital or analog records detailing a patient’s visit to the clinic. It consists of the medical treatment the patient has received, the timing of the patient’s check-in and check-out, and specific diagnoses and procedures encrypted into the ICD and CPT codes to represent a patient’s clinical status. Its accuracy is directly related to the improved quality and patient safety outcomes and increased reimbursement; it helps to conduct the quality audit of the medical services offered and investigate any severe incidents in the patient’s care, and as far as the timely reimbursement is concerned accuracy is the most prior legislative requirement if there is a lack of information regarding patient’s test it can cause unnecessary delays and possibly even denial of reimbursements. In these circumstances, we are here to demonstrate the best practices to overcome the risks of poor document management workflow in healthcare.

What constitutes poor medical record documentation?

In general, poor documentation lacks clarity, specificity, or completeness, probably because of the inaccurate diagnosis and procedure code assignment. Per the HCPRO demonstration, incomplete medical documentation defines that insufficient medical care was provided, which does not comply with the regulatory regulations and is used to support allegations of negligence and fraud.

If the clinical documentation consists of billing and coding flaws, it fails to convey the patient’s problem concisely, and the logic to address that problem will put the patient’s safety at risk, and efforts also get weak to estimate the quality of the rendered care. Furthermore, it will also cause medical providers to face a loss in practice revenue and unnecessary, expensive diagnostic studies, face legislative penalties, and lose their medical licenses.

Factors that play a role in poor patient documentation

Lack Of Education:
Most CDI experts put the insufficient provider education factor at the top of the list, which is a fundamental reason for patient documentation failure. Physicians are extremely busy providing medical care to patients; therefore, they lack an understanding of the specific information that needs to be included for coding purposes. A lot of information needs to be documented. Still, due to a lack of education, there is a shortfall in the clarity of their handwriting that is unable to define the highest level of specificity.

Lack Of Time:
Providers cannot document a patient’s visit because they have a flow of patients in their clinics, and it is their prior responsibility to spend most of the time providing medical care to their patients. In this way, patient documentation becomes their secondary priority. Documentation problems can be solved if physicians spend more time creating the patient’s document, but the bitter fact is there is a lack of motivation for clinicians to provide remarkable documentation. EHR Complications: Although EHR has improved the readability concerns of the documentation, it has also led to significant concerns regarding the manual work of copy and pasting within medical records. According to Dr. Dan Siegel, EHR can improve documentation in the long term if certain boxes are checked first. Most significantly, he says software vendors must work closely with users, both clinicians, and coders, to make meaningful adjustments.

Best practices to overcome the risks of poor document management workflow

Patient documentation is considered incomplete by Medicare if it fails to tell the patient’s whole story and lacks clarity, specificity, or completeness. From the insurance auditor’s viewpoint, documentation is incomplete if it contains insufficient documentation errors, including Incomplete progress notes, Unauthenticated medical records, and missing signed orders describing the intent for services to be provided. Inadequate records can cause medical providers to support medical negligence and fraud allegations.

Therefore, there is a crucial need to apply best practices for documentation improvement, including gap analysis, competitor analysis, and deploying an efficient CDI program. A good clinical documentation program must comprise the following characteristics and functions:

Convey effectively through documentation

The primary focus of clinical documentation integration for medical providers is to convey the office environment through adequate documentation. For example, if the physician diagnoses the co-morbidities during the patient’s medical treatment, he must include the existence and status of the co-morbidities in the documentation. Additionally, if the physician’s decision-making is critically dependent on the patient’s medical history, it is essential to include a summary of that history and its impacts on the treatment options in the documentation.

Must keep auto-generated notes separately

Electronic health records are often limited to the automated patient record population, which doesn’t always provide the necessary details to explain the patient’s visit to the clinic. The limited choices afforded by these tools may result in generic patient records. Still, the patient documentation may vary from patient to patient. To overcome this limitation of auto-generated text in the EHR, the physician must add a note of one or two lines to the record that describes concisely how this note is unique and what is unique to this patient at this visit.

Imply a subjective, objective, and assessment plan

The Subjective, Objective, Assessment, and Plan (SOAP) is a widely used method of creating clinical documentation for medical providers. This standard method allows medical providers to create a document in a structured and organized way. The widely adopted structural SOAP note assists healthcare providers in assessing, diagnosing, and treating patients based on their information. This checklist structured documentation comprises essential information about the patient’s health status and the communication between the patients and medical providers.

E/M leveling must narrate the true nature of the visit

Typically, EHRs use a modern web application framework for documentation templates. These types of documentation contain general, sealed statements conducive to documentation requirements for an evaluation and management (E/M) level for an office visit, regardless of the nature of the presenting problem. The best practice is to transform these templates with physician narrative free-typed text that describes the true nature of the visit.

Implement Gap Analysis:
The gap analysis must be a part of the CDI program to address the issue of budget constraints. It helps evaluate the actual business performance that can be measured against optimal performance levels across multiple areas of the business, including customer satisfaction, revenue generation, productivity, and supply chain cost. So following are the gap analysis that will guide the development of the CDI to identify where the greatest effects are:

Elements Of An Effective CDI Program:

1. Quality And Compliance: The approach to medical treatment and the process must be based on the rules and regulations that accurately reflect the severity of the illness.
2. Teamwork And Integration: Clinical and coding expertise must be leveraged through a process and approach that is based on cooperation and collaboration.
3. Knowledge And Education: The complexity is high, and compliance is required. Therefore, medical providers must be made aware of the importance of accurate and complete documentation to improve patient care and also positively impact their profile.
4. Process Measurement And Feedback:Must identify the patient safety indicators and hospital-acquired conditions. In severe circumstances, query whether or not these conditions exist at the time of the patient’s admission.

If flaws exist in the clinical documentation regarding quality, compliance, systems/technology,  monitoring, and management, it could be the leading cause of getting overwhelmed under the malpractice lawsuit allegations that can be very distressing for physicians and medical providers. However, implementing an effective CDI program allows medical providers to record and track the patient’s information accurately and provides a smooth healthcare experience for all concerned entities, including patients, healthcare practitioners, and billing companies.

Speak with clinical documentation experts at MedsIT Nexus

MedsIT Nexus medical billing and coding services are driven by a highly proficient workforce that comprises CDI professionals and AAPC-certified billing and coding professionals who are capable enough to assess the current billing and coding procedures and provide suggestions as well as the quality resources to help clients in receiving the best outcomes from our clinical documentation services.