When it comes proper documentation, here’s what the Bethlehem, PA-based consulting firm of HP3 says are fundamental rules every practice should follow:
Medical documentation should be complete, clear, and specific.
The attending physician is the ultimate authority for determining what kind of clinical documentation goes in a patient’s records.
Physicians should document the rationales behind their treatment decisions. For example, when a test or drug is ordered for a patient, the physician should document the diagnosis or differential diagnoses he or she is treating, confirming, or ruling out.
Improved documentation is an ongoing process, not a one-time or occasional effort. It must embrace every person involved in the coding and documentation chain, including physicians, case managers, nurse managers, coding professionals, other clinicians, and compliance officers.