Transcript Documentation and the Medical Record

Chapter 7
Documentation and the
Medical Record
Learning Objectives







Define the term medical record.
State the connection between the medical record and
insurance billing process.
Recite principles for the release of medical information
for various situations
Explain reasons for medical record documentation
Name various types of reports that make up a medical
record.
Name various types of medical review and state what an
audit or medical records entails.
Explain techniques used to maintain confidentiality of
faxed documents.
Chapter 7
2
Learning Objectives




Respond appropriately to the subpoena of a witness and
records.
Express the purpose of a compliance program and recite
elements that lead to a successful program.
State ways to prevent legal problems and lawsuits
Performance Objectives

Abstract data from the medical record, including date of
service, place of service, and elements of a history and
physical examination (subjective & objective information)
chief complaint, symptoms, diagnosis, and procedure or
service.
Chapter 7
3
Key Terms








Attending physician
audit
backup
comorbidity
Compliance program
Concurrent care
Consulting physician
Continuity of care
Chapter 7






documentation
external audit
family history (FH)
History of present
illness (HPI)
internal review
medical record
4
Key Terms








medical necessity
morbidity
mortality
objective finding
ordering physician
past history (PH)
performing physician
physician examination
(PE or PX)
Chapter 7






referring physician
review of systems
(ROS)
social history (SH)
subjective information
subpoena
treating physician
5
The Medical Record

Understanding the Medical Record and
Documentation Guidelines is the
Foundation to learning the skill of medical
record abstraction.


This skill takes time to learn and improves each
time it practiced.
Developing a methodical system to abstract
information from a Medical Record is the first
step in mastering this job skill after the basic
foundation has been laid.
Chapter 7
6
The Medical Record

A Medical Record can be defined as a
Legal Document displaying written or
graphic information detailing facts and
events during the rendering of patient
care.
Chapter 7
7
Abstracting Information from a
Medical Recording

Information to Complete an Insurance Claim
Form





Date of Service (DOS)
Place of Service (POS)
Type of Service (TOS)
Diagnosis (dx or DX) and;
Procedures & Services
Chapter 7
8
Abstracting Information from a
Medical Recording

Key to substantiating Procedure & Diagnostic Code
selection for Reimbursement:
 Documentation (must be)


Accurate, legible, specific, clear, and concise
Must have sufficient detail to describe the level of
service provided & all procedures performed
Chapter 7
9
Abstracting Information from a
Medical Recording

Sending a Letter to Justify a Health Insurance
Claim


When submitting a health insurance claim form the
Medical Insurance Billing Specialist makes decision
as to whether additional documentation is needed to
substantiate the claim
Additional documentation include:
 Chart notes,
 Operative report, or
 Discharge summary
Chapter 7
10
Abstracting Information from a
Medical Recording

Request from an Insurance Company

Insurance companies may request information about:






Pre-exiting conditions
specific diagnoses
Or because the patient is applying for some type of insurance.
Sufficient detail to describe the level of service provided & all
procedures performed
To avoid liability have physician read information to
verify that the information is accurate.
Send the information to the Insurance Company with a
note to state. “Please Read”.
Chapter 7
11
Photocopying the Medical Record

Insurance Company

Sent a duplicating service to the physician’s office to
photocopy records






Standard time is set aside in the physician’s office for this service
Remove records to be copied from the chart
Have the physician review the records, and
Be sure a consent or authorization is in place to release medical
information.
Advise the photocopy company of the standard fee prior to
duplicating records.
If information communicated in the records are beyond standards,
physicians can request a fee based on the length of report or form,
and bill using CPT code 99080.
Chapter 7
12
The Documentation Process
SOAP

Subjective Information (S)


Objective Findings (O)



Reason for the encounter, chief complaint, symptoms.
Facts and finding.
Data from physical exam, x-rays, laboratory and other
diagnostic tests
After all Objective Information is Obtained: (A) &
(P)


The Physician Assesses the subjective and objective
information
Put it all together, and formulates a diagnosis and a
Treatment Plan.
Chapter 7
13
Chapter 7
14
Chapter 7
15
Record Systems

Three basic types of record systems used by
most physician’s offices:
1. The problem-oriented record
2. The source-oriented record
3. The integrated medical record

Each system incorporates subjective & objective
information, along with the assessment of the patient
and the formulation of a treatment plan.
Chapter 7
16
Record Systems
1. Problem-Oriented Record System (POR)


POR system organizes information within the
medical record according to patient problems.
Four parts of the system include:




A database
Problem list
Initial plan and
Progress notes
Chapter 7
17
Record Systems
2. Source-Oriented (SOR)


SOR system the most common paper-based
management system, arranges information in
the medical record according to its source, or
according to the practitioners who are the
source of the treatment, as well as of the data
collected.
Advantage


Is the speed which a specific sheet of information can
be located
Disadvantage:

The lack of a clear picture portraying a specific
patient problem, because the documentation related
to it is filed in different sections of the medical record
Chapter 7
18
Record Systems
3.
Integrated Medical Record



Integrated medical records files all documents
in chronological order, regardless of their
source.
Each episode of care is clearly defined by date,
except laboratory test results.
Depending on the practice:

Laboratory Test Results/Reports are defined in a
separate section of the medical record.
Chapter 7
19
Documentation

Documentation - details chronologic
recording of pertinent facts and
observations about a patient’s health, as
seen in chart notes and medical reports;
entries in the medical record such as
prescription refills, telephone calls,
other pertinent data.
Chapter 7
20
Documentation

Methods of Documentation:



Handwritten
Computer Input
Dictation & Transcription
Chapter 7
21
Documentation

Physician’s title defined in the Medical
Record:


Attending Physician – refers to the medical staff
member who is legally responsible for the care and
treatment given to a patient
Consulting Physician – is a provider whose opinion
or advice regarding evaluation and/or management of
a specific problem is requested by another physician.
Chapter 7
22
Documentation



Ordering Physician – is the individual directing the
selection, preparation, or administration of tests,
medication, or treatment. The Attending Physician
can also be the ordering physician.
Referring Physician – is a provider who sends the
patient for testing or treatment.
Treating or performing Physician – is the provider
who renders a service to a patient.
Chapter 7
23
Documentation

Medical Record Fraud


Tampering with a medical record is a Fraudulent Act
 Considered a criminal offense
 Sanctions can include a monetary fine, prison time
or both.
Litigation



Scientific test can be done to determine the record’s
validity.
Paper and ink can be analyzed
Writing instruments can be determined, and
indentation analyzed to determine if alterations took
place.
Chapter 7
24
Reason for Documentation




Avoidance of denied or delayed payments by
insurance carriers who investigate the medical
necessity of service.
Enforcement of medical record-keeping rules
by insurance carriers who require accurate
documentation that support procedure and
diagnostic codes
Subpoena of medical records by state
investigators for review by the court
Defense of a professional liability claim.
Chapter 7
25
General Principles of Medical
Record Documentation

Documentation Guidelines were
developed by HCFA (Health Care
Financing Administration) Now known as
“Center for Medicare and Medicaid
Services (CMS)”, for Current Procedural
Terminology (CPT), Evaluation &
Management services in 1995, and later
modified in 1997.
Chapter 7
26
General Principles of Medical
Record Documentation

Development of Guidelines

Came from auditing by Medicare of
physicians’ medical records and
discovering that the quality of
documentation needed to be improved.

The Medical Necessity of procedures and services
that had been performed were not stated clearly in
the medical record.
Chapter 7
27
General Principles of Medical
Record Documentation
Medical Necessity – the performance of
services or procedures are consistent with
the diagnosis, in accordance with standards
of good medical practice performed at the
proper level, and provided in the most
appropriate setting.

If a treatment is questioned as to whether it is
medically necessary, the authorization to
perform the treatment or the payment may
delayed or denied.
Chapter 7
28
General Principles of Medical
Record Documentation
Documentation Guidelines For E/M:








Detailed and lengthy
They state all the elements necessary to keep a
complete record on the patient
States chart entries should be dated and signed
including what each encounter should contain
Which diagnoses need to be stated
The patient’s health risks, the patient progress
What role consulting physicians have in the care
and treatment of the patient
How treatment plans should be written
Chapter 7
29
General Principles of Medical
Record Documentation
Documentation Guidelines For E/M (Cont):






Procedure & Diagnostic codes reported on the health
insurance claim form or billing statement should be supported
by the documentation in the medical record
Documentation in the medical record should be written at a
level that a clinical peer could determine if the services
have been accurately coded.
A list of commonly used abbreviations should be complied
and posted throughout the office to ensure consistency when
documenting the medical record
Chart entries should be dated, and signed including the title or
position of the person signing
Write neatly, & use a permanent, not water-soluble, ink pen
(legal copy pen)
Chapter 7
30
General Principles of Medical
Record Documentation
Corrections to the Medical Record



Malpractice



Use a legal copy pen and cross-out incorrect entry
using a one single line
Write the correct information and then date and initial
the entry
If pending, never erase, white-out, or use self-adhesive
paper over any information recorded on the patient
record.
Documentation should answer
questions, not raise them!
Chapter 7
31
General Principles of Medical
Record Documentation

Missing Documentation





An addendum may be preferable.
Addendum to the chart should include the
original chart note that is being added to and
the date it was prepared/transcribed
Signed by the physician or the person adding
additional documentation
Addendum should be entered in or attached to
the chart after the last entry.
If there are entries between it and the original
entry, a cross-reference at the original entry
should be noted (see Fig. 7-3, page 178)
Chapter 7
32
General Principles of Medical Record
Documentation
(Medical Terms used in Documentation)
Medical Terms used in Documentation Concurrent
Care – is the provision of similar services (e.g., hospital
visits) to the same patient by more than one physician on
the same day. Usually, there is the presence of a separate
physical disorder (heart, arrhythmia) at the same time as
the primary admitting diagnosis.

Example: A General Internist admitted the patient for
diabetes and request a cardiologist to follow the
patient’s arrhythmia.

When billing the insurance company for services, both
physicians’ services must be identified on the claim
form to avoid duplication and denial of services.
Chapter 7
33
General Principles of Medical Record
Documentation
(Continuity of Care)

Continuity of Care – Continued treatment of a patient
who is referred by one physician to another for the same
condition.

Example: If a cancer patient receives chemotherapy
treatment from his or her oncologist and is then referred to a
Radiologist for radiology treatment, both physician’s are
responsible for providing arrangements for the patient’s
continuing care.


The referring physician (Oncologist) must provide records to the
Radiologist.
The Radiologist must provide a reasonable appointment time &
follow-up to ensure that records needed to perform the service are in
his or her possession.
Chapter 7
34
Components of A Medical Record

Medical Record – Written or graphic information
documenting facts and events during the rendering of
patient care.

Operative Reports – consent to perform special
treatment or services.
Chapter 7
35
Components of A Medical Record
Content of a Medical Report based upon:




Complexity of service
New PT
Established PT
Documentation of History



Based on 1997 Guidelines
History




CC (chief complaint)
HPI (history of present illness)
ROS (review of systems
PFSH (past, family, and/or social history)
Chapter 7
36
Components of A Medical Record
History


Chief Complaint – a brief statement, in the patient’s own
words, describing the reason for the encounter; such as a
symptom, problem, condition, or finding.

History of Present Illness – is a chronological
description of the development of the patient’s present illness
from the first sign and/or symptom or from the previous
encounter to the present.

Review of System – is an inventory of all body systems
obtained through a series of questions that are used to identify
signs and/or symptoms that the patient has experienced or
might be experiencing.
Chapter 7
37
Components of A Medical Record

Past, Family, and Social History (PFSH) –
consist of:




Past History (PH) – patient’s past experiences with illness,
operations, injuries, and treatment
Family history (FH) – review of medical events in the
patient’s family, including diseases that may be hereditary or
place the patient at risk.
Social history (SH) review of past and current activities
depending on patient’s age.
Documentation of Physical Exam


Physical examination (PE or PX) – consist of the
physician’s findings by examination and/or test results of
organ systems or body areas.
The Extent of the exam depends on the clinical judgment
and the nature of the presenting problem(s).
Chapter 7
38
Components of A Medical Record

Documentation of Medical Decision-Making

The physician must look at the number of diagnoses and
treatment options, the amount and/or complexity of data
to be reviewed, and the risk of complication and/or
morbidity or mortality.



Morbidity – diseased condition or state
Mortality – number of deaths in a given time or place
Comorbidity – underlying disease or other condition present at
the time of the visit.
Chapter 7
39
Components of A Medical Record

Documentation for Requesting
Outpatient Services

When a physician orders outpatient services to
be done at another facility, documentation on
the order must include:

Date of order

Patient’s name

Service ordered

Diagnosis or signs/symptoms

Physician’s signature
Chapter 7
40
Legalities of a Medical Record
Consent form must be signed and in patient’s
medical record

Faxing Confidential Information


AHIMA (The American Health Information Management
Association) advises that fax machines “should not be used
for routine transmission of patient information.”
Chapter 7
41
Legalities of a Medical Record

AHIMA recommends that documents should
be faxed only when:

Hand or mail delivery will not meet the
needs of immediate patient care or;

Required by a third party for ongoing
certification of payment for a hospitalized
patient.
Chapter 7
42
Legalities of a Medical Record
Fax Machines must be secure or restricted access.

A cover sheet must be used with the
transmission. It must contain:
Date, Name of sender with fax & telephone number
Name of recipient with fax & telephone number
Total number of pages, including cover sheet
Statement privileged & confidential.

Chapter 7
43
Legalities of a Medical Record
What not to Fax (status of)




Financial information & documents containing
information on sexually transmitted diseases
Drug or alcohol treatment
Human Immunodeficiency virus (HIV)
Psychiatric records
Chapter 7
44
Legalities of a Medical Record

Transmittal Destination

To ensure Fax has reached correct destination:
Arrange a scheduled time for transmission with the recipient.
 Telephone the destination to verify receipt.
 Request that the authorized receiver sign and return an
attached receipt form at the bottom of the cover sheet after
receiving the faxed information.
 Send the fax to a coded mail box that only allow a receiver who
has the code that was used to fax the information to activate the
printer.
 Arrange with the recipient to block out the name of the
patient’s Social Security number

Chapter 7
45
Legalities of a Medical Record
Faxing Legal Documents


Criterias are the same for faxing confidential documents,
except:

The attorney must be consulted to make sure that the
documents (contracts, proposal, etc) requiring signatures
are legally binding if faxed.
Subpoena




Must have the physician prior approval
The attorney usually employs a person or a duplication
service to photocopy records that are under subpoena.
Prevention of Legal Problems

Insurance Billers must follow guidelines topic entitled
“Prevention of Lawsuits”
Chapter 7
46
Data Storage
Medical Record Retention



Preservation of medical records is governed by State and
Local Laws.
Policy of Physicians

To retain medical records of all living patients,
indefinitely

Records such as x-ray films, laboratory reports,
and pathologic specimens probably should also
be kept indefinitely

Deceased patients’ charts should be kept for at
least 5 years.

Calendars, appointment books and telephone
logs should be filed and stored.
Chapter 7
47
Data Storage
Financial Document Retention



Keep Tax Records for 7 years
And Tax returns permanently
A federal regulation mandates:


that assigned claims for Medicaid and Medicare be kept for
years.
Destruction of Medical Records



Shred no longer needed
Maintain a log of all destroyed records, showing the
patient’s name, date of birth, SS#, date of last visit, and
date destroyed
Chapter 7
48
Auditing a Medical Record
Audit – is a formal, methodical examination or
review done to inspect, analyze, and scrutinize the
way something is being done (e.g., bookkeeping
practices, medical record documentation, insurance
claim filing practices).
The purpose of an audit



Is to verify that the documentation support the services
and procedures that are being submitted to the patient or
insurance carrier for payment and that proper care is being
provided.
Chapter 7
49
Auditing a Medical Record
During performance of an Audit a Point System is
used:

Points are awarded only if documentation is present for
elements required in the medical record

The Point System is used to show where deficiencies
occur in medical record documentation.

Also used to evaluate and substantiate proper use of
diagnostic and procedure codes.
Managed Care Organizations (MCO), Government & Private
Insurance carriers who have a contract with physicians have the
right to audit medical records and may claim refunds in the event
of accidental or intentional miscoding.



If improper coding patterns exist and are not corrected, the
provider of service will be penalized.
Chapter 7
50
Auditing a Medical Record

Billing patterns that may draw attention for a
possible Audit:





Intentional billing for unnecessary services
Incorrect billing for services of physician extenders
(e.g., nurse practitioner, physician assistant)
Diagnostic testing billed without a separate report in
the medical record.
Dates of service changed on insurance claims in
order to comply with policy coverage dates
Co-payments or deductibles waived without good
reason and documentation
Chapter 7
51
Auditing a Medical Record
Billing patterns that may draw attention for a
possible Audit: (cont)






Discounts given illegally
Excessive diagnostic tests ordered
Provider identification numbers misused resulting in
incorrect billing (e.g., two different provider numbers
used to bill the same service for the same patient)
Improper Modifiers used to obtain financial gain
Overpayments not returned to the Medicare program
Chapter 7
52
Auditing a Medical Record
Internal Review


Two types of Internal review:
1. Prospective Review – done before billing is submitted.

Done to verify that completed encounter forms match all
patients seen according to the appointment schedule and all
service/procedures have been posted on the day sheet.

All procedures/services and diagnoses listed on the
encounter forms are then matched with the data on the
insurance claim forms.
2. Retrospect Review – done after the billing

Done by randomly pulling 15 to 20 medical records from the
last 2 to 4 months and reviewing them to determine whether
there is a lack of documentation.
Chapter 7
53
Auditing a Medical Record
External Audit – is a retrospective review
(review done after claims have been billed) of
medical and financial records by an insurance
company or Medicare representative to
investigate suspected fraudulent and abusive
billing practices.
Chapter 7
54
Auditing a Medical Record

Compliance Program – is a Management Plan
composed of policies and procedures to accomplish
uniformity, consistency, and conformity in medical
record keeping that fulfills official requirements.

Developed in 1997

The Concept ask physicians to volunteer to
develop & implement compliance programs in their
offices.

The Goal of a compliance program is to improve the
quality of care to patients, control claim
submissions, and reduce fraudulent insurance
claims, abuse, waste and the cost of healthcare to
federal, state, and private health insurers.
Chapter 7
55
Auditing a Medical Record

Benefits of a Compliance Program:

Effective internal procedures that
ensure compliance with regulations,
payment policies, and coding rules

Improved medical record
documentation

Reduction of denied claims

Reduced exposure to penalties
(cont’d…)
Chapter 7
56
Auditing a Medical Record
(

Avoidance of potential liability
stemming from non-compliance

Streamlined practice operations
through comprehensive policies and
improved communication.
REMEMBER THE GOLDEN RULE!
NOT DOCUMENTED, NOT DONE!
Chapter 7
57