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BUSINESS OF
MEDICINE

counter, which might be
particularly problematic in
an electronic health record
(EHR) system because of
reliance on form fields and
check boxes.

Content
Content-related concerns in-
clude problems such as altered
documentation (which might
suggest an attempt to cover up
mistakes), opinions stated as
medical facts, inappropriate
comments or speculation (e.g.,
subjective vs. objective infor-
mation), the proliferation of
inaccurate information as a re-
sult of the copy/paste func-
tion in EHRs, or general
inconsistencies in documenta- follow-up with the patient, patient response, and phone conver-
tion patterns across records. sations (including after-hours calls).
• Consultations and referrals, including conversations with the
Mechanics. consulting provider, agreed-upon consulting arrangements, and
The mechanics category refers to inaccurate documentation receipt and review of consultation reports.
within a factual setting. Examples include inaccuracies in transcrib- • Patient education, including written and verbal advice, recom-
ing or writing orders, illegibility (including the use of nonstandard mendations, and educational materials — as well as patient un-
abbreviations, shorthand, or “text talk”), delays in documenting, derstanding of the information.
and failure to use an appropriate method for correcting documen- • Establish appropriate timeframes for completion of documen-
tation errors and making amendments. tation following patient encounters.
• Consider whether documentation in the record supports clinical
Documentation Risk Tips judgment and decision-making, and whether it clearly identifies
Because of documentation's essential role in healthcare, following how a particular diagnosis was determined.
best practices and standards is crucial. The following key risk man- • Do not include incident reports or criticism of other providers
agement strategies can help ensure adequate and appropriate docu- in patient records. Root cause analysis of errors and near-misses
mentation. should be documented as part of the practice’s risk management
Ensure your organization’s documentation policies and quality improvement efforts.
require providers to document: • Understand and educate staff about the appropriate methods
• Sufficient details related to the patient’s history and physical for correcting or amending documentation.
exam. This documentation will help support continuity of care • Ensure that documentation policies address issues unique to
and comparison of findings from previous visits. electronic documentation, such as the use of copy/paste, form
• Patient compliance, including missed and cancelled appoint- fields, check boxes, etc.
ments and attempts to follow up with the patient. Providers
should be careful to remain objective in their documentation For more helpful documentation strategies, see MedPro’s Docu-
and avoid editorializing. mentation Essentials and Electronic Documentation checklists at
• Treatment plan changes, such as receipt of diagnostic results, its website – www.medpro.com.

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