Medical documentation tips for
Are you documenting right? Tips to survive
RAC audits and reimbursement cuts!
• Documenting in today’s healthcare landscape is a
unique challenge in itself. Improper documentation and
being overly dependent on EHR templates, has
snowballed into a huge issue.
Tips to help you beat documentation blues!
• Being timely is important.
• History and physical notes should be
signed within 24 hours of seeing the patient.
• Operative notes should be documented and signed
within 24 hours of the operation.
• Medical records will have to be completed within a week
of the patient’s discharge.
• Work swiftly to avoid delays that will throw your
documentation workflow out of gear.
• Document clearly and don’t skip the details. The more
detailed and specific a physician’s documentation is the
higher the reimbursement. It can help medical coders
freeze on the right codes and improvise on patient care.
• Don’t use EHR shortcuts and pick-lists to document your
patient records. Depending completely on them can lead
to selective and restricted documentation. Customize
your EHRs or use paper charts to record important
• Expand your SOAP notes to document more clearly. Add
patient quotes and opinions in the Subjective section.
Use reproducible and supportive medical data.
Document the various treatment options you discussed
with patients. This will add more credence and acts as
helpful additional documentation while filing claims.
• Hire cross-trained staff. Documentation has become
more complex, extensive, detailed and the single most
important component across the care continuum. It
requires skilled and trained personnel to handle and
maintain your practice’s documentation.
• It is healthy practice to start documenting records as
quickly as possible. Just a few hastily scribbled notes
during the patient encounter can go a long way… Always
have a scribble pad in hand to jot down those important
details, if you find logging into your EMR every single
• Always cross verify the data inputted into your EMR,
spotting discrepancies before they metasize into an
enormous problem, is important, especially at a time
when medical practitioners are working under intense
• Conduct internal audits regularly. A few
sporadic proofing and verifying
sessions won’t work. It is the
responsibility of physicians to check
the medical records for accuracy
before signing them.
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