MEDICAL DOCUMENTATION

Healthcare providers are responsible for documenting and authenticating
legible, complete, and timely patient records in accordance with federal regulations
(e.g., Medicare Conditions of Participation) and accrediting agency
standards (e.g., The Joint Commission).

The provider is also responsible for correcting or altering errors in patient record documentation. A patient record (or medical record) documents healthcare services provided to a patient, and
healthcare providers are responsible for documenting and authenticating legible, complete, and timely entries according to federal regulations and accreditation standards. The records include patient demographic (or identification) data, documentation to support diagnoses and justify treatment
provided, and the results of treatment provided.


 The primary purpose of the record is to provide for continuity of care, which involves documenting patient care services so that others who treat the patient have a source of information
to assist with additional care and treatment. The record also serves as a communication tool for physicians and other patient care professionals, and assists in planning individual patient care and documenting a patient’s illness and treatment.

include:
● Evaluating the quality of patient care.
● Providing data for use in clinical research, epidemiology studies, education, public
policy making, facilities planning, and healthcare statistics.
● Providing information to third-party payers for reimbursement.
● Serving the medico-legal interests of the patient, facility, and providers of care.
Documentation includes dictated and transcribed, typed or handwritten,
and computer-generated notes and reports recorded in the patient’s records by a
healthcare professional. Documentation must be dated and authenticated (with
a legible signature or electronic authentication). In a teaching hospital, documentation
must identify what service was furnished, how the teaching physician
participated in providing the service, and whether the teaching physician
was physically present when care was provided. A teaching hospital is engaged
in an approved graduate medical education (GME) residency program in medicine,
osteopathy, dentistry, or podiatry. A teaching physician is a physician
(other than another resident physician) who supervises residents during patient
care. A resident physician is an individual who participates in an approved
GME program. (Physicians who are authorized to practice only in a hospital
setting are called hospitalists; some facilities also call them residents.)
Documentation in the patient record serves as the basis for coding. The information
in the record must support codes submitted on claims for third-party
payer reimbursement processing. The patient’s diagnosis must also justify diagnostic
and/or therapeutic procedures or services provided. This is called medical
necessity and requires providers to document services or supplies that are:

● Proper and needed for the diagnosis or treatment of a medical condition.
● Provided for the diagnosis, direct care, and treatment of a medical condition.
● Consistent with standards of good medical practice in the local area.
● Not mainly for the convenience of the physician or healthcare facility.
It is important to remember the familiar phrase “If it wasn’t documented, it wasn’t
done.” The patient record serves as a medico-legal document and a business
record. If a provider performs a service but does not document it, the patient (or
third-party payer) can refuse to pay for that service, resulting in lost revenue for
the provider. In addition, because the patient record serves as an excellent defense
of the quality of care administered to a patient, missing documentation can result
in problems if the record has to be admitted as evidence in a court of law.
eXaMPle:

Missing Documentation: A representative from XYZ Insurance Company
reviewed 100 outpatient claims submitted by the Medical Center to
ensure that all services billed were documented in the patient records.
Upon reconciliation of claims with patient record documentation, the
representative denied payment for 13 services (totaling $14,000) because
reports of the services billed were not found in the patient records. The
facility must pay back the $14,000 it received from the payer as reimbursement
for the claims submitted.

lack of Medical Necessity: The patient underwent an x-ray of his right
knee, and the provider documented “severe right shoulder pain” in the
record. The coder assigned a CPT code to the “right knee x-ray” and an
ICD code to the “right shoulder pain.” In this example, the third-party

payer will deny reimbursement for the submitted claim because the
reason for the x-ray (shoulder pain) does not match the type of x-ray
performed. For medical necessity, the provider should have documented
a diagnosis such as “right knee pain.”
Support of Medical Necessity: The patient underwent a chest x-ray, and
the provider documented “severe shortness of breath” in the record. The
coder assigned a CPT code to “chest x-ray” and an ICD code to “severe
shortness of breath.” In this example, the third-party payer will reimburse
the provider for services rendered because medical necessity for
performing the procedure has been shown.

Problem-oriented Record (POR)
The problem-oriented record (POR) is systematic method of documentation that
consists of four components:
● Database
● Problem list
● Initial plan
● Progress notes
The POR database contains the following patient information collected on each
patient:
● Chief complaint
● Present conditions and diagnoses
● Social data
● Past, personal, medical, and social history
● Review of systems
● Physical examination
● Baseline laboratory data
The POR problem list serves as a table of contents for the patient record because
it is filed at the beginning of the record and contains a numbered list of the
patient’s problems, which helps to index documentation throughout the record.
The POR initial plan contains the strategy for managing patient care and any
actions taken to investigate the patient’s condition and to treat and educate him
or her. The initial plan consists of three categories:
● Diagnostic/management plans (plans to learn more about the patient’s condition
and the management of the conditions).
● Therapeutic plans (specific medications, goals, procedures, therapies, and treatments
used to treat the patient).
● Patient education plans (plans to educate the patient about conditions for which
he or she is being treated).
The POR progress notes are documented for each problem assigned to the
patient, using the SOAP format:
● Subjective (S) (patient’s statement about how he or she feels, including symptomatic
information [e.g., “I have a headache”]).


● Objective (O) (observations about the patient, such as physical findings, or lab or
x-ray results [e.g., chest x-ray negative]).
● assessment (a) (judgment, opinion, or evaluation made by the healthcare provider
[e.g., acute headache]).
● Plan (P) (diagnostic, therapeutic, and education plans to resolve the problems
[e.g., patient to take Tylenol as needed for pain]).