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Documentation Do's and Don't's

Updated: Sep 13, 2019


Effective and accurate documentation is a must for reimbursement. While it will demand a lot of your time and attention, effective documentation is an essential element for a clinician and supports our value as a skilled expert in our respective areas of practice.

Documentation Do’s

Do document timely. To accurately report events and patient responses document timely. Point of service or soon thereafter is best practice. Progress Reports and POC completion must also be timely. Payment guidelines

require timely documentation.

Do be thorough. If you don’t document it, it didn’t happen. When defending your services, only the medical records will be able to speak for you. Include all pertinent information in the record to justify the need for your skilled care as well as justification for your decision making regarding the patient’s care. Include education topics and audiences.

Do make every record individualized. Make every record client specific. The documentation should paint a clear picture of the patient. Remember your record will be all the reader has to determine if your services were warranted. The note for your 16-year-old knee patient should be different than the note for your 50-year-old knee patient.

Do ensure your treatment note reflects the time billed. The treatment note should support the time billed for each session. A note for a 50- minute session should be more involved than a note for a 20-minute session. They shouldn’t be identical. If the patient required additional time to complete a task than expected be sure to include that information in the record. It will help justify the time billed

if reviewed.

Documentation Don’ts

Don’t copy and paste. Each note should be different to justify the need for your presence as a subject area expert. This will further justify your interventions and the need for the interventions. Repetitive tasks and language give the impression that the intervention requires little to no clinical reasoning, adjustment and could safely be performed by a non-skilled person.

Don’t use slang or unapproved abbreviations. Unclear terms, slang, non-standard abbreviations and misspelled words can lead to confusion. Items that contain confusing language or terms will likely be discredited. Use approved abbreviations only along with medical terminology to support the need for the provided complex and sophisticated skilled services.

Don’t only document a list of the tasks performed by the patient. Remember the service being paid is for the clinician’s service, not for what the patient has done. The note should contain a description of the intervention; however, it should clearly establish the skills and clinical reasoning utilized by the clinician during the session. Why was it necessary for you to be present? Explain how the chosen will assist the patient to achieve goals.

Over the past few years in healthcare, compliance has become a very hot topic. What is a compliance program? Simply put, a system of policies, guidelines and procedures, developed to assure compliance and conformity to laws and regulations. According to the Office of the Inspector General (OIG) an effective compliance program should have seven fundamental elements. The OIG is part of the Department of Health and Human Services, and its main role is to fight fraud and abuse in Medicare, Medicaid, and other HHS programs.

The Seven Elements are:

1. Written policies and procedures

2. Compliance officer and committee

3. Effective lines of communication

4. Education and Training

5. Effective Auditing and Monitoring

6. Discipline for non-compliance

7. Investigation promptly of detected offenses

Each of the 7 elements are important; however, for the purposes of this article, we will discuss the 5th listed element:

Effective Auditing and Monitoring

Auditing and monitoring help the organization identify and reduce potential risk for overpayment or improper behavior. Establishing internal audits makes rehab directors, leaders and the compliance officer aware of risk factors so corrective action can begin.

What is the difference between auditing and monitoring? Audit: An organized review and assessment of current practice to identify specific improper practices. Monitor: A part of risk management for an organization; regular activities performed to identify potential improper practices, outliers and practices that may need further attention.

Audits are performed to ensure departments and the organization are following laws pertaining to HIPAA, coding rules, claims development and submission.

Mid South has a multi-tiered audit process. Currently the auditor spans from the facility level by the rehab director or peers to the corporate level by the medical review nurse or compliance officer.

Once a potential issue or improper practice is identified on any audit level, corrective action should be implemented in a timely manner.

Auditing is an important component of every compliance program. As an organization, we must inspect what we expect. Education and monitoring are required to achieve continuous improvement. We all play an important role in our compliance program. Together we can make it happen!

Charlean Williams, OTR/L, CHC, RAC-CT

Director of HIM & Compliance


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