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The domino effect of incomplete documentation
May 23, 2018

This article is intended for providers, coding and billing staff, office managers, and clinical documentation improvement specialists.

To deliver the best care possible, clinicians rely on medical records to tell the patient’s whole story, starting with progress notes. Detailed medical records also help coders and billers submit claims, which leads to more accurate reimbursement from the patient’s health plan. 

Complete and accurate progress notes include five key components:

  • Patient name
  • Date of birth
  • Date of service
  • All conditions that impact the medical decision-making during the visit
  • A valid signature with credentials

A complete medical record shows a true 360 degree picture of a patient’s health status that providers rely on when seeing a patient for an annual wellness visit or an acute concern. Medical decision-making, assessment, and planning should consider these elements of the medical record:

  • Updated problem lists that reflect chronic conditions
  • Active medication lists with links to the conditions
  • Prior medical and surgical information

How an incomplete medical record impacts the patient
In contrast, incomplete documentation may lower the quality of care a patient receives and put a patient’s health at risk. Consider a patient whose current medication list notes that the patient takes a medication but the past medical history does not note the condition being treated. The provider – and others involved in the patient’s care -- may fail to consider this condition when developing their treatment plan. Or, consider how missing a medication in the current medication list could result in a serious drug interaction.

How an incomplete medical record impacts the practice
Incomplete or inaccurate documentation can hurt a practice financially. The coding and billing team is responsible for making sure the claim accurately reflects the medical record. Then, the practice is reimbursed accordingly.

When documentation is insufficient, your billers and coders may bill for unspecific diagnosis codes or lower level E/M codes that result in missed revenue opportunities. Inconsistent, insufficient, and/or illegible medical records that do not support what was coded and billed can negatively impact provider organizations during a payment audit.  

Closing the gaps: Best practices
Here are some ways to make sure the five key components are included in your medical records:

  • Check the chart after each update to make sure each element is included.
  • Enlist your nursing staff, coding, and billing teams in a clinical documentation improvement program to identify gaps in documentation.
  • Remain current on coding guidelines and attend coding clinics to learn best practices.

By creating internal standards and quality checks that focus on these elements in the medical record, you’re setting the stage for quality care and financial success.


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