1. Documentation and the Medical Record
Chapter 7
Documentation and the Medical Record

2. Learning Objectives Define the term medical record.
State the connection between the medical record and insurance billing process.
Recite principles for the release of medical information for various situations
Explain reasons for medical record documentation
Name various types of reports that make up a medical record.
Name various types of medical review and state what an audit or medical records entails.
Explain techniques used to maintain confidentiality of faxed documents.
Chapter 7

3. Learning Objectives Performance Objectives
Respond appropriately to the subpoena of a witness and records.
Express the purpose of a compliance program and recite elements that lead to a successful program.
State ways to prevent legal problems and lawsuits
Performance Objectives
Abstract data from the medical record, including date of service, place of service, and elements of a history and physical examination (subjective & objective information) chief complaint, symptoms, diagnosis, and procedure or service.
Chapter 7

4. Key Terms documentation external audit family history (FH)
Attending physician
audit
backup
comorbidity
Compliance program
Concurrent care
Consulting physician
Continuity of care
documentation
external audit
family history (FH)
History of present illness (HPI)
internal review
medical record
Chapter 7

5. Key Terms medical necessity morbidity mortality objective finding
ordering physician
past history (PH)
performing physician
physician examination (PE or PX)
referring physician
review of systems (ROS)
social history (SH)
subjective information
subpoena
treating physician
Chapter 7

6. The Medical Record
Understanding the Medical Record and Documentation Guidelines is the Foundation to learning the skill of medical record abstraction.
This skill takes time to learn and improves each time it practiced.
Developing a methodical system to abstract information from a Medical Record is the first step in mastering this job skill after the basic foundation has been laid.
Chapter 7

7. The Medical Record
A Medical Record can be defined as a Legal Document displaying written or graphic information detailing facts and events during the rendering of patient care.
Chapter 7

8. Abstracting Information from a Medical Recording
Information to Complete an Insurance Claim Form
Date of Service (DOS)
Place of Service (POS)
Type of Service (TOS)
Diagnosis (dx or DX) and;
Procedures & Services
Chapter 7

9. Abstracting Information from a Medical Recording
Key to substantiating Procedure & Diagnostic Code selection for Reimbursement:
Documentation (must be)
Accurate, legible, specific, clear, and concise
Must have sufficient detail to describe the level of service provided & all procedures performed
Chapter 7

10. Abstracting Information from a Medical Recording
Sending a Letter to Justify a Health Insurance Claim
When submitting a health insurance claim form the Medical Insurance Billing Specialist makes decision as to whether additional documentation is needed to substantiate the claim
Additional documentation include:
Chart notes,
Operative report, or
Discharge summary
Chapter 7

11. Abstracting Information from a Medical Recording
Request from an Insurance Company
Insurance companies may request information about:
Pre-exiting conditions
specific diagnoses
Or because the patient is applying for some type of insurance.
Sufficient detail to describe the level of service provided & all procedures performed
To avoid liability have physician read information to verify that the information is accurate.
Send the information to the Insurance Company with a note to state. “Please Read”.
Chapter 7

12. Photocopying the Medical Record
Insurance Company
Sent a duplicating service to the physician’s office to photocopy records
Standard time is set aside in the physician’s office for this service
Remove records to be copied from the chart
Have the physician review the records, and
Be sure a consent or authorization is in place to release medical information.
Advise the photocopy company of the standard fee prior to duplicating records.
If information communicated in the records are beyond standards, physicians can request a fee based on the length of report or form, and bill using CPT code
Chapter 7

13. The Documentation Process SOAP
Subjective Information (S)
Reason for the encounter, chief complaint, symptoms.
Objective Findings (O)
Facts and finding.
Data from physical exam, x-rays, laboratory and other diagnostic tests
After all Objective Information is Obtained: (A) & (P)
The Physician Assesses the subjective and objective information
Put it all together, and formulates a diagnosis and a Treatment Plan.
Chapter 7

14. Chapter 7

15. Chapter 7

16. Record Systems
Three basic types of record systems used by most physician’s offices:
The problem-oriented record
The source-oriented record
The integrated medical record
Each system incorporates subjective & objective information, along with the assessment of the patient and the formulation of a treatment plan.
Chapter 7

17. Record Systems 1. Problem-Oriented Record System (POR)
POR system organizes information within the medical record according to patient problems.
Four parts of the system include:
A database
Problem list
Initial plan and
Progress notes
Chapter 7

18. Record Systems 2. Source-Oriented (SOR)
SOR system the most common paper-based management system, arranges information in the medical record according to its source, or according to the practitioners who are the source of the treatment, as well as of the data collected.
Advantage
Is the speed which a specific sheet of information can be located
Disadvantage:
The lack of a clear picture portraying a specific patient problem, because the documentation related to it is filed in different sections of the medical record
Chapter 7

19. Record Systems 3. Integrated Medical Record
Integrated medical records files all documents in chronological order, regardless of their source.
Each episode of care is clearly defined by date, except laboratory test results.
Depending on the practice:
Laboratory Test Results/Reports are defined in a separate section of the medical record.
Chapter 7

20. Documentation
Documentation - details chronologic recording of pertinent facts and observations about a patient’s health, as seen in chart notes and medical reports; entries in the medical record such as prescription refills, telephone calls, other pertinent data.
Chapter 7

21. Documentation Methods of Documentation: Handwritten Computer Input
Dictation & Transcription
Chapter 7

22. Documentation Physician’s title defined in the Medical Record:
Attending Physician – refers to the medical staff member who is legally responsible for the care and treatment given to a patient
Consulting Physician – is a provider whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician.
Chapter 7

23. Documentation
Ordering Physician – is the individual directing the selection, preparation, or administration of tests, medication, or treatment. The Attending Physician can also be the ordering physician.
Referring Physician – is a provider who sends the patient for testing or treatment.
Treating or performing Physician – is the provider who renders a service to a patient.
Chapter 7

24. Documentation Medical Record Fraud Litigation
Tampering with a medical record is a Fraudulent Act
Considered a criminal offense
Sanctions can include a monetary fine, prison time or both.
Litigation
Scientific test can be done to determine the record’s validity.
Paper and ink can be analyzed
Writing instruments can be determined, and indentation analyzed to determine if alterations took place.
Chapter 7

25. Reason for Documentation
Avoidance of denied or delayed payments by insurance carriers who investigate the medical necessity of service.
Enforcement of medical record-keeping rules by insurance carriers who require accurate documentation that support procedure and diagnostic codes
Subpoena of medical records by state investigators for review by the court
Defense of a professional liability claim.
Chapter 7

26. General Principles of Medical Record Documentation
Documentation Guidelines were developed by HCFA (Health Care Financing Administration) Now known as “Center for Medicare and Medicaid Services (CMS)”, for Current Procedural Terminology (CPT), Evaluation & Management services in 1995, and later modified in 1997.
Chapter 7

27. General Principles of Medical Record Documentation
Development of Guidelines
Came from auditing by Medicare of physicians’ medical records and discovering that the quality of documentation needed to be improved.
The Medical Necessity of procedures and services that had been performed were not stated clearly in the medical record.
Chapter 7

28. General Principles of Medical Record Documentation
Medical Necessity – the performance of services or procedures are consistent with the diagnosis, in accordance with standards of good medical practice performed at the proper level, and provided in the most appropriate setting.
If a treatment is questioned as to whether it is medically necessary, the authorization to perform the treatment or the payment may delayed or denied.
Chapter 7

29. General Principles of Medical Record Documentation
Documentation Guidelines For E/M:
Detailed and lengthy
They state all the elements necessary to keep a complete record on the patient
States chart entries should be dated and signed including what each encounter should contain
Which diagnoses need to be stated
The patient’s health risks, the patient progress
What role consulting physicians have in the care and treatment of the patient
How treatment plans should be written
Chapter 7

30. General Principles of Medical Record Documentation
Documentation Guidelines For E/M (Cont):
Procedure & Diagnostic codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record
Documentation in the medical record should be written at a level that a clinical peer could determine if the services have been accurately coded.
A list of commonly used abbreviations should be complied and posted throughout the office to ensure consistency when documenting the medical record
Chart entries should be dated, and signed including the title or position of the person signing
Write neatly, & use a permanent, not water-soluble, ink pen (legal copy pen)
Chapter 7

31. General Principles of Medical Record Documentation
Corrections to the Medical Record
Use a legal copy pen and cross-out incorrect entry using a one single line
Write the correct information and then date and initial the entry
Malpractice
If pending, never erase, white-out, or use self-adhesive paper over any information recorded on the patient record.
Documentation should answer questions, not raise them!
Chapter 7

32. General Principles of Medical Record Documentation
Missing Documentation
An addendum may be preferable.
Addendum to the chart should include the original chart note that is being added to and the date it was prepared/transcribed
Signed by the physician or the person adding additional documentation
Addendum should be entered in or attached to the chart after the last entry.
If there are entries between it and the original entry, a cross-reference at the original entry should be noted (see Fig. 7-3, page 178)
Chapter 7

33. General Principles of Medical Record Documentation (Medical Terms used in Documentation)
Medical Terms used in Documentation Concurrent Care – is the provision of similar services (e.g., hospital visits) to the same patient by more than one physician on the same day. Usually, there is the presence of a separate physical disorder (heart, arrhythmia) at the same time as the primary admitting diagnosis.
Example: A General Internist admitted the patient for diabetes and request a cardiologist to follow the patient’s arrhythmia.
When billing the insurance company for services, both physicians’ services must be identified on the claim form to avoid duplication and denial of services.
Chapter 7

34. General Principles of Medical Record Documentation (Continuity of Care)
Continuity of Care – Continued treatment of a patient who is referred by one physician to another for the same condition.
Example: If a cancer patient receives chemotherapy treatment from his or her oncologist and is then referred to a Radiologist for radiology treatment, both physician’s are responsible for providing arrangements for the patient’s continuing care.
The referring physician (Oncologist) must provide records to the Radiologist.
The Radiologist must provide a reasonable appointment time & follow-up to ensure that records needed to perform the service are in his or her possession.
Chapter 7

35. Components of A Medical Record
Medical Record – Written or graphic information documenting facts and events during the rendering of patient care.
Operative Reports – consent to perform special treatment or services.
Chapter 7

36. Components of A Medical Record
Content of a Medical Report based upon:
Complexity of service
New PT
Established PT
Documentation of History
Based on 1997 Guidelines
History
CC (chief complaint)
HPI (history of present illness)
ROS (review of systems
PFSH (past, family, and/or social history)
Chapter 7

37. Components of A Medical Record
History
Chief Complaint – a brief statement, in the patient’s own words, describing the reason for the encounter; such as a symptom, problem, condition, or finding.
History of Present Illness – is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
Review of System – is an inventory of all body systems obtained through a series of questions that are used to identify signs and/or symptoms that the patient has experienced or might be experiencing.
Chapter 7

38. Components of A Medical Record
Past, Family, and Social History (PFSH) – consist of:
Past History (PH) – patient’s past experiences with illness, operations, injuries, and treatment
Family history (FH) – review of medical events in the patient’s family, including diseases that may be hereditary or place the patient at risk.
Social history (SH) review of past and current activities depending on patient’s age.
Documentation of Physical Exam
Physical examination (PE or PX) – consist of the physician’s findings by examination and/or test results of organ systems or body areas.
The Extent of the exam depends on the clinical judgment and the nature of the presenting problem(s).
Chapter 7

39. Components of A Medical Record
Documentation of Medical Decision-Making
The physician must look at the number of diagnoses and treatment options, the amount and/or complexity of data to be reviewed, and the risk of complication and/or morbidity or mortality.
Morbidity – diseased condition or state
Mortality – number of deaths in a given time or place
Comorbidity – underlying disease or other condition present at the time of the visit.
Chapter 7

40. Components of A Medical Record
Documentation for Requesting Outpatient Services
When a physician orders outpatient services to be done at another facility, documentation on the order must include:
Date of order
Patient’s name
Service ordered
Diagnosis or signs/symptoms
Physician’s signature
Chapter 7

41. Legalities of a Medical Record
Consent form must be signed and in patient’s medical record
Faxing Confidential Information
AHIMA (The American Health Information Management Association) advises that fax machines “should not be used for routine transmission of patient information.”
Chapter 7

42. Legalities of a Medical Record
AHIMA recommends that documents should be faxed only when:
Hand or mail delivery will not meet the needs of immediate patient care or;
Required by a third party for ongoing certification of payment for a hospitalized patient.
Chapter 7

43. Legalities of a Medical Record
Fax Machines must be secure or restricted access.
A cover sheet must be used with the transmission. It must contain:
Date, Name of sender with fax & telephone number
Name of recipient with fax & telephone number
Total number of pages, including cover sheet
Statement privileged & confidential.
Chapter 7

44. Legalities of a Medical Record
What not to Fax (status of)
Financial information & documents containing
information on sexually transmitted diseases
Drug or alcohol treatment
Human Immunodeficiency virus (HIV)
Psychiatric records
Chapter 7

45. Legalities of a Medical Record
Transmittal Destination
To ensure Fax has reached correct destination:
Arrange a scheduled time for transmission with the recipient.
Telephone the destination to verify receipt.
Request that the authorized receiver sign and return an attached receipt form at the bottom of the cover sheet after receiving the faxed information.
Send the fax to a coded mail box that only allow a receiver who
has the code that was used to fax the information to activate the
printer.
Arrange with the recipient to block out the name of the patient’s Social Security number
Chapter 7

46. Legalities of a Medical Record
Faxing Legal Documents
Criterias are the same for faxing confidential documents, except:
The attorney must be consulted to make sure that the documents (contracts, proposal, etc) requiring signatures are legally binding if faxed.
Subpoena
Must have the physician prior approval
The attorney usually employs a person or a duplication service to photocopy records that are under subpoena.
Prevention of Legal Problems
Insurance Billers must follow guidelines topic entitled “Prevention of Lawsuits”
Chapter 7

47. Data Storage Medical Record Retention Policy of Physicians
Preservation of medical records is governed by State and Local Laws.
Policy of Physicians
To retain medical records of all living patients, indefinitely
Records such as x-ray films, laboratory reports, and pathologic specimens probably should also be kept indefinitely
Deceased patients’ charts should be kept for at least 5 years.
Calendars, appointment books and telephone logs should be filed and stored.
Chapter 7

48. Data Storage Financial Document Retention
Keep Tax Records for 7 years
And Tax returns permanently
A federal regulation mandates:
that assigned claims for Medicaid and Medicare be kept for years.
Destruction of Medical Records
Shred no longer needed
Maintain a log of all destroyed records, showing the patient’s name, date of birth, SS#, date of last visit, and date destroyed
Chapter 7

49. Auditing a Medical Record
Audit – is a formal, methodical examination or review done to inspect, analyze, and scrutinize the way something is being done (e.g., bookkeeping practices, medical record documentation, insurance claim filing practices).
The purpose of an audit
Is to verify that the documentation support the services and procedures that are being submitted to the patient or insurance carrier for payment and that proper care is being provided.
Chapter 7

50. Auditing a Medical Record
During performance of an Audit a Point System is used:
Points are awarded only if documentation is present for elements required in the medical record
The Point System is used to show where deficiencies occur in medical record documentation.
Also used to evaluate and substantiate proper use of diagnostic and procedure codes.
Managed Care Organizations (MCO), Government & Private Insurance carriers who have a contract with physicians have the right to audit medical records and may claim refunds in the event of accidental or intentional miscoding.
If improper coding patterns exist and are not corrected, the provider of service will be penalized.
Chapter 7

51. Auditing a Medical Record
Billing patterns that may draw attention for a
possible Audit:
Intentional billing for unnecessary services
Incorrect billing for services of physician extenders (e.g., nurse practitioner, physician assistant)
Diagnostic testing billed without a separate report in the medical record.
Dates of service changed on insurance claims in order to comply with policy coverage dates
Co-payments or deductibles waived without good reason and documentation
Chapter 7

52. Auditing a Medical Record
Billing patterns that may draw attention for a possible Audit: (cont)
Discounts given illegally
Excessive diagnostic tests ordered
Provider identification numbers misused resulting in incorrect billing (e.g., two different provider numbers used to bill the same service for the same patient)
Improper Modifiers used to obtain financial gain
Overpayments not returned to the Medicare program
Chapter 7

53. Auditing a Medical Record
Internal Review
Two types of Internal review:
Prospective Review – done before billing is submitted.
Done to verify that completed encounter forms match all patients seen according to the appointment schedule and all service/procedures have been posted on the day sheet.
All procedures/services and diagnoses listed on the encounter forms are then matched with the data on the insurance claim forms.
Retrospect Review – done after the billing
Done by randomly pulling 15 to 20 medical records from the last 2 to 4 months and reviewing them to determine whether there is a lack of documentation.
Chapter 7

54. Auditing a Medical Record
External Audit – is a retrospective review (review done after claims have been billed) of medical and financial records by an insurance company or Medicare representative to investigate suspected fraudulent and abusive billing practices.
Chapter 7

55. Auditing a Medical Record
Compliance Program – is a Management Plan composed of policies and procedures to accomplish uniformity, consistency, and conformity in medical record keeping that fulfills official requirements.
Developed in 1997
The Concept ask physicians to volunteer to develop & implement compliance programs in their offices.
The Goal of a compliance program is to improve the quality of care to patients, control claim submissions, and reduce fraudulent insurance claims, abuse, waste and the cost of healthcare to federal, state, and private health insurers.
Chapter 7

56. Auditing a Medical Record
Benefits of a Compliance Program:
Effective internal procedures that ensure compliance with regulations, payment policies, and coding rules
Improved medical record documentation
Reduction of denied claims
Reduced exposure to penalties
(cont’d…)
Chapter 7

57. Auditing a Medical Record(
Avoidance of potential liability stemming from non-compliance
Streamlined practice operations through comprehensive policies and improved communication.
REMEMBER THE GOLDEN RULE!
NOT DOCUMENTED, NOT DONE!
Chapter 7