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Introduction

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If there is no documentation, then it did not happen! This philosophy is the standard in all health care settings as physicians, nurses, respiratory therapists, physical therapists, social workers, and other healthcare providers generate and maintain detailed notes regarding the patient’s condition and their efforts to achieve the best possible outcomes for the patient. Documentation chronologically outlines the care the patient received and serves as a form of communication among healthcare practitioners, an important element that contributes to the quality of care provided. Each practitioner involved knows what evaluation has occurred, what the patient’s treatment plan is, and who will provide it. Furthermore, third-party payers may require reasonable documentation from practitioners that assures that the services provided are consistent with the insurance coverage.1 General components of documentation include:

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  • A complete and legible record;

  • Documentation for each encounter with a rationale for the encounter, physical findings, prior test results, assessment, clinical impression (or diagnosis), and plan for care;

  • Identified health risk factors, and an easily inferred rationale for ordering diagnostic tests or ancillary services; and

  • The patient’s progress, response to and changes in treatment, and revision of the original diagnosis/assessment.

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Traditionally, this documentation was paper based. These records are often inaccessible at the point of patient care, not easily transferable or transportable, illegible, poorly organized, and often may be missing key information. Due to these limitations, many academic centers and healthcare systems have developed and implemented electronic health records (EHRs). Further, Crossing the Quality Chasm was published in 2001 by the Institute of Medicine. This report identified the EHR as a key component to improve access to medical information, facilitate decision support and collection of data, and reduce medical errors.2 The EHR may also assist in improved documentation, with reduced clinical variation and better provision of quality preventative and chronic care.35 Furthermore, use of EHR features in primary care is associated with higher performance on certain quality measures.6

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Principles of Documentation

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Documentation in the record is required to record pertinent facts, findings, and observations about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. Particularly in an era of evolution of EHRs,7 it also facilitates:

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  • The ability of providers to evaluate and plan the patient’s immediate treatment and monitor his or her health care over time;

  • Communication and continuity of care among providers involved in the patient’s care;

  • Accurate and timely claims review and payment;

  • Appropriate utilization review and quality of care evaluations;

  • Collection of data that may be useful for research and education; and

  • Appropriate coding (i.e., Current Procedural Terminology [CPT] and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification [ICD-10-CM], from the World Health Organization) for use on health insurance claim forms should be supported by documentation in the patient record.

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Much of this documentation ...

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