Common Medical Practice Documentation Pitfalls to Avoid

October 9, 2013
Aubrey Westgate

Great documentation at your medical practice will boost revenue. Is your practice doing all it can to ensure physicians are documenting correctly?

Great documentation at your medical practice will boost revenue, and it will help validate the services your physicians provide. But there are some common documentation mistakes made at many practices that are keeping them from getting paid what they deserve.

That's according to Deborah Robb, director of physician services at health information management services and revenue cycle management consultancy TrustHCS in Springfield, Mo., and Lori Lowe, the consultancy's director of physician coding operations.

During their Tuesday session at the Medical Group Management Association Annual Conference, "Getting it Right: How to Improve Physician Documentation in Practice," Robb and Lowe identified some of these common documentation bad habits, as well as some tips for how practices can better train physicians to improve documentation.

Common bad habits. The transition from paper to EHRs at many practices has led to some common documentation missteps. Here are some of the key issues identified by Robb and Lowe:

1. Getting "click happy." This mistake occurs when physicians click every box possible in the EHR, often in hopes that it will increase the level of service provided.

2. Using inappropriate dropdowns. This occurs when physicians select dropdowns that don't specifically relate to the diagnosis at hand, said Robb. "I'll have providers tell me, 'I'm just going to pick what's close.'" The problem, she said, is that "what's close" might not be what's accurate.

3. Copying. This occurs when physicians take a previous note and copy it over to the current visit and fail to adjust it appropriately. "Yes you can carry information over, but you have to actually validate today's visit," said Robb, noting that vitals, weight, and more may have changed and those changes should be documented. 

4. Pasting. This occurs when physicians copy and paste another provider's note, and then fail to make enough changes to it. 

5. Forgetting to document. This occurs when physicians fail to document appropriately. They say things like, "I did that, I didn't document it but I did it," said Robb. "If it's not documented, it's not done.

6. Failing to sign. This occurs when physicians document appropriately but fail to sign the documentation.

7. Free texting. This occurs when physicians free text in the EHR. The problem is that free text is not recognized by most EHRs, and the content is then not counted towards the level of service, said Lowe.

Fixing bad habits. To ensure physicians are not making these common mistakes and that they are documenting appropriately, here are four of the recommendations Robb and Lowe shared:

1. Assess the EHR. Consider whether changes need to be made to the EHR. For instance, ensure check boxes are specific enough and that dropdown boxes are relevant.

2. Conduct an audit. This will help your practice identify areas of documentation weakness that you can then work to improve. One way to get started? Take a few charts per provider and see what is missing in documentation, whether diagnoses are described to the highest specificity, and so on.

At this time, you may even want to assess how documentation will fare when it comes time to transition to ICD-10, said Robb. "If you work on your documentation now, be proactive, then these are things down the line that will come a lot easier for you."

3. Create a training program. Use audit findings to identify specific training areas, then target training by provider or group, said Robb, adding that training should be specialty specific. "Sit down with the provider, have a worksheet, and go through that and say, 'Did you realize you were missing this?'" she said. "A lot of times people think, 'I know, I write that every time,' and low and behold it's not there."

4. Create a training manual. A training manual, including guidance on the different components needed for various visits, will be a useful resource for your physicians moving forward. Here are some areas to consider including in your training manual:
• Documentation guidelines
• Office or other outpatient visits
• Inpatient hospital visits
• Initial hospital care services
• Subsequent hospital visits and discharge-management services
• Consultations
• Critical care
• Incident-to services
• Observation care
• Prolonged services
• Split/shared E&M service
• Local coverage determination
• Examples of E&M service

"They don't have to memorize any of this but at least they have a ready reference if the question is there," said Robb.