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INTRODUCTION

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If you didn’t document it, then it hasn’t been done. This adage is the standard in all healthcare settings because all providers must generate and maintain clear and concise records of each patient’s health and medical conditions for enhancing workflow, usability, and patient safety, all critical components of quality patient care.1 Further, documentation is required for providers to receive accurate and timely payment for services. Documentation outlines the care the patient received in a chronological and organized manner, and serves as a form of communication among practitioners, which is 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 documentation from practitioners that assures that the services provided are consistent with the insurance coverage.1,2 General components of documentation include:

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  • A complete and legible record;

  • Date of service, site of service, and identity of the practitioner;

  • Documentation for each encounter with a rationale for the encounter, physical findings, prior test results, and identified health risk factors;

  • An easily inferred rationale for ordering diagnostic tests or ancillary services, assessment, clinical impression (or diagnosis), and plan for care; and

  • Patient progress, response to and changes in treatment, and revision of the original diagnosis/assessment.

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Traditionally, this documentation was paper based; however, such records are often inaccessible at the point of care, not easily transferable or transportable, illegible, poorly organized, and missing key information. Due to these limitations, many academic centers and healthcare systems have developed and implemented electronic health records (EHRs). Further, the 2001 Institute of Medicine report Crossing the Quality Chasm identified the EHR as a key component in improving provider access to medical information, facilitating decision support and data collection, and reducing medical errors and associated costs.3 The EHR may also improve documentation with reduced clinical variation, better provision of quality preventative and chronic care, and increased security of confidential patient information.4,5,6,7 Furthermore, EHRs are associated with higher performance on certain quality measures.8,9,10

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PRINCIPLES OF DOCUMENTATION

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Documentation includes pertinent facts, findings, and observations about a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. With the growth of EHRs, other benefits have been identified:6,9

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  • Enhanced ability of providers to evaluate care, plan immediate treatment, and monitor care over time;

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

  • More accurate and timely claims review and payment;

  • Improvement in the quality of care provided;

  • Increased time efficiency;

  • Greater adherence to practice guidelines;

  • Fewer medication errors and adverse drug events;

  • More appropriate utilization review and quality of care evaluations; and

  • Greater clarity of coding (ie, Current Procedural Terminology [CPT] and International Statistical Classification of Diseases and ...

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