Getting your documentation done: What works best for completing patient charts

Documentation of the patient encounter is an important component of a physician practice’s revenue cycle process. Timely, accurate charting is necessary to ensure that appropriate reimbursement occurs, and sufficient documentation is present should the service require a prior authorization, the claim be pended, denied, or the payment audited. Understanding the significance of capturing the clinical documentation, the goal should be to complete the patient’s chart no later than the same day of appointment.

The physician burden associated with EHR data entry is well established. Lack of keyboarding skills, excessive use of the "cutting and pasting" technique combined with the challenge of physicians entering the data after the patient visit has led to issues with the accuracy of the documentation. The more time that passes between the health event and data entry, the more likely the data will be generic rather than detailed. This increases the margin of error from the physician or via incorrect hand-off communications. Delayed data entry affects patient outcomes, creates unnecessary administrative overhead and can decrease reimbursement. 

Claims have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed (that is, the reviewer could not conclude that some of the allowed services were provided, were provided at the level billed or were medically necessary). Also placed in this category are claims that lack a specific required documentation element as a condition of payment, such as a physician signature on an order or a form that is required to be completed in its entirety.

The Medical Group Management Association's most recent MGMA Stat poll asked healthcare leaders to describe, in their words, how their organization completes patient visit documentation. The responses to the question indicated that 58% utilize EHR entry (typing, clicking or using templates), 55% utilize dictation software (such as Dragon and other talk-to-text software), 31% report the use of scribes, 7% maintain hand-written documentation and 2% employ transcription services. This poll was conducted on Dec. 4, 2018, with 709 applicable responses.

Practices have adopted creative solutions more accurately complete charting. Using real-time charting requires technology and intelligent field mapping to reduce data entry time or scribes to take notes at the time of the visit. What is the best option for completing chart notes? It varies with each practice and their preferences. Here are a couple to consider:

• Medical transcription is now typically cloud-based, using secure cutting-edge technologies such as smartphone dictation, remote EHR connectivity and natural language processing to extract structured data elements from narrative. The pros are that the physician's full narrative is captured and the automatic insertion into specific EHR sections reduces physicians' keyboard and mouse usage. Finally, accuracy is easier to achieve because dictation is typed verbatim and reviewed by the doctor who will catch discrepancies between what was said and what was typed. 
• Scribes are also popular among clinicians who want data entry and other non-medical tasks to be completed in near real-time during patient encounters. The pros are that documentation is captured in the EHR in (nearly) real time, giving the clinician more meaningful time with patients. This also untethers them from their computers. The risk is that there are no certification or training standards, or background for understanding medical and legal issues. It presents hiring challenges such as expense and turnover. There are also risks associated with over-documentation, patient safety and malpractice.

As practices are looking at opportunities to both reduce physician burden and improve accuracy, it is important to remember the leading causes of insufficient documentation errors identified by the CERT Review Contractor (RC):

• Incomplete progress notes (for example, unsigned, undated, insufficient detail);
• Unauthenticated medical records (for example, no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures); and
• No documentation of intent to order services and procedures (for example, incomplete or missing signed order or progress note describing intent for services to be provided).

With these rules in mind, every practice needs an electronic record or other documentation policy/protocol. 

MGMA Stat is a national poll that addresses practice management issues, the impact of new legislation and related topics. Participation is open to all healthcare leaders. See results of other polls and information on how to participate in MGMA Stat. 

Resources:

• Click here to download your copy of the MLN Fact Sheet ICN 909160.Real-time charting in EHR
• Read insights from Halee Fischer-Wright, MD, MMM, FAAP, CMPE,  in "A treatment for physician burnout: Freeing doctors to become better leaders"
• Access the MGMA Research & Analysis report Maximizing patient access and scheduling 

Pamela Ballou-Nelson, PhD, RN, MSPH, CMPE
Pincipal
MGMA Consulting