Clinical Documentation: Why is it so Important?

Posted on 8 Sep, 2017 |comments_icon 0|By Elizabeth

Documentation helps to inform and support providers by supplying information to highlight trends, providing insight into disease processes, and uniting physician teams and payers through the flow of data.

Clinical records provide uniformity and continuity across visits, hospitals, physicians, and payer providers.

Bottom Line: Documentation is the physician’s best weapon in his arsenal to maximize both patient care and payer reimbursement.

Clear Up Confusion with Routine Checks for Quality Control

Healthcare professionals rely on the accuracy of correct patient information to create and evaluate treatment plans and monitor patient healthcare over time. Therefore, it is imperative that physicians audit their medical records frequently to identify any potential issues before they become a problem.

Beware the Snowball Effect

Undetected problems in medical records can fester, impacting everything that is later built upon that faulty information, including billing for services that may not have been provided.

Pitfall: Once payers get involved, physicians could find themselves facing possible fraud and abuse charges – all based on a simple mistake or oversight that snowballed out of control. Providers must be able to justify their claims with accurate, timely, and comprehensive clinical documentation.

Chart Out the Patient Encounter

Documentation provides a valuable account of a patient’s concerns, as described to the physician, and the physician’s assessment of, and findings about, the patient’s condition and resulting treatment plans. Documentation provides an electronic record (and usually also a hard copy).

Furthermore, since it is ultimately the physician’s responsibility to establish the cause and effect relationship of the disease process, a fully documented record provides him with the tools he needs to make that determination.

Providers are mandated by law and regulatory bodies to capture some form of record about an encounter with each patient. These notes provide a baseline from which any provider can build, review, and follow up on treatment plans.

Important: From this record, physicians determine or modify treatment plans, chart disease progression, and craft an entire case history.

The record allows the entire healthcare delivery team to provide quality patient care. Additionally, the fully documented patient record is the physician’s best chance of receiving complete reimbursement for services rendered on the patient’s behalf.

You Can Only Bill What Has Been Documented

Many of us already know this familiar phrase, “If it has not been noted in the record, then it never happened.” A procedure must be indicated and substantiated on the chart and included in the Electronic Medical Record (EMR) for the payers (and auditors) to accept a claim for that service.

Bottom Line: Regardless of what procedures the physician performs – and how mandatory or integral it is that the procedure be performed in line with the rest of the documented services – if a particular procedure is not documented, it does not get reimbursed. Period.

Remember: Payers determine eligibility for payment through the documentation submitted to substantiate the claim. Providers should ensure that their documentation accurately and meticulously reflects a full picture of the encounter. This will, in turn, maximize reimbursement and revenue.

Good documentation supports:

  • Accountability: Accessible records provide a system of checks and balances and allow for transparency in healthcare.
  • Communication: Precise and clear-cut documentation helps in proper communication and dissemination of information within the circle of care. Accurate information can make a big difference in the patient condition.
  • Detection of comorbid conditions: Proper documentation can also help increase the possibility of detecting comorbid conditions that may be responsive to treatment.
  • Validation of care: In situations where questions about billing or care occur, records allow individuals to easily substantiate charges and the treatment provided.
  • Compliance: Documentation must follow a set of regulations and guidelines designed to enhance record-keeping, which in turn leads to a higher quality of patient care.
  • Healthcare analytics: Proper documentation assures healthcare analytics, allowing providers to run statistical analysis on their patient population and services they render.
  • Billing accuracy: The more specific the diagnosis, the more thorough the documentation, the better equipped the coder is to do her job. Thus, a lower the rate of subsequent denials. Result: everyone is happy.

The above factors are especially important with clinical documentation improvement (CDI). To learn more about the value of documentation—and to get the inside scoop on CDI methods and strategies—pick up your copy of TCI’s must-have Clinical Documentation Sourcebook.



Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of telehealth services.

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