AAO-HNSF Certificate Program for Otolaryngology Personnel

BENEFITS OF GOOD MEDICAL RECORD DOCUMENTATION

Providing good medical record documentation aids in the quality assurance process. Having well-organized and legible medical records allows the auditor a clear picture of the patient’s complaint, symptoms, procedures, or actions to alleviate or eliminate the patient’s illness or injury, status of the patient condition following treatment, and final outcome. A well-maintained medical record facilitates the collection of data that may be useful for education or research within your practice. Nurses and allied health professionals can also look to the medical record to evaluate the progress of the patient as it pertains to their individual care plan. Contractual obligations with Health Maintenance Organizations (HMO’s), require good documentation to ensure that consistent service is being given to the patient. Medical records can also be used by HMOs to verify pertinent information such as the site of service, medical necessity, and diagnostic, therapeutic, or ancillary services. Good documentation holds true for ICD-9-CM codes on health insurance claim forms and with reimbursement from Medicare and Medicaid. If you were to be challenged by an auditor for your billing practices by the HMO, Medicare, or Medicaid, the medical record could be used to validate the services rendered. Poor documentation or coding may increase the potential for an intensified audit that might place you in jeopardy of losing you participation in Medicare and Medicaid. As we have seen, there are many reasons for maintaining complete, detailed, and legible medical records. They paint a picture of why the patient has come to see you, your clinical findings, and your treatment plans. They are your best protection in a malpractice suit and show justification in your billing procedures if you were to be audited. The most important concept to remember in striving for good medical record documentation is, “If you didn’t write it down, you didn’t do it.” n * Risk Management Specialist, Illinois State Medical Insurance Services, Inc., 20 N. Michigan Avenue, Suite 700, Chicago, IL 60602; phone: 800-782-4767; E-mail: Murphy@ismie.com. The material in this article was prepared by the Risk Management Division of the Illinois State Medical Inter-Insurance Exchange under the direction of its eight-member Physician Risk Management Committee. CONCLUSION

Copyright © 2001 by Greenbranch Publishing LLC.