Chapter 5: Documentation of Patient Encounters and Interventions

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INTRODUCTION

To ensure high-quality patient care, especially in the current environment of increasingly complex care, all healthcare providers must generate and maintain clear and concise records of each patient’s health and medical conditions.^1,2 Documentation is also 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 ensures that the services provided are consistent with the insurance coverage.^1,2 General components of documentation include:

• 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, relevant history, 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

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

• Applicable diagnostic and treatment codes

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), which have greatly enhanced workflow, usability, and patient safety.² 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 preventive and chronic care, and increased security of confidential patient information.^4–7 Furthermore, EHRs are associated with higher performance on certain quality measures.^1,8

PRINCIPLES OF DOCUMENTATION

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, additional benefits have been identified^4,7,9–11:

• Enhanced ability of providers across the continuum of care 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

• New modes of communicating with patients and providing them information about their care

• More accurate and timely claims review and payment

• Improvement in the quality of care provided

• Increased time efficiency

• Greater adherence to ...