Medical record keeping is a vital element in providing the care that patients need and medical transcription companies play a vital role in ensuring accurate and timely documentation. Medical records help healthcare providers evaluate the patient’s profile, make accurate diagnosis, analyze treatment results, and plan treatment protocols. Medical records with sufficient and accurate information is also important for proper billing and to protect the healthcare professional in case of alleged negligence. Given the importance of good medical record keeping, it is easy to understand the consequences of incomplete patient documentation.
What is an incomplete medical record? An incomplete medical record is one that fails to tell the patient’s whole story, and lacks clarity, specificity, or completeness. Poor quality documentation puts patient safety at risk.
From an auditor’s viewpoint, if it’s not documented, it didn’t happen. Medicare CERT audits have identified insufficient documentation errors as including the following:
- Incomplete progress notes (e.g., unsigned, undated, insufficient detail, etc.)
- Unauthenticated medical records – no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures
- No documentation of intent to order services and procedures – incomplete or missing signed order or progress note describing intent for services to be provided
Medicare considers claims to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed. Another example of incomplete documentation is not recording the patient’s chief complaint. Chief complaints are critical as they support medical necessity (www.ahima.org).
According to HCPro, an incomplete medical record demonstrates that care was incomplete, contains gaps reflecting poor clinical care, demonstrates noncompliance with organizational policies, and is used to support allegations of negligence and allegations of fraud. The consequences of incomplete medical records are:
- Lack of clarity in communication between physicians treating the patient leading to failure to follow through with evaluation and treatment plans
- Incorrect treatment decisions compromising patient safety
- Loss of practice revenue
- Unnecessary and expensive diagnostic studies
- Inappropriate billing
- Affects patient-related studies
Clear, accurate, complete and legible medical records report the relevant clinical findings, decisions made, drugs prescribed or other investigations or treatment, and information provided to patients. To ensure complete and accurate medical records, make sure that clinical notes include the following elements:
- Patient demographics
- Reasons for current visit
- Scope of exam
- Exam findings – positive as well as key abnormal findings
- Clear management plan and agreed actions
- Treatment plan and future treat recommendations
- Medicines administered prescribed, and renewed
- Any drug allergies
- Instructions and educational info given to patient
- Documentation of communication with the patient’s family/friends
- Recommended return visit date
Entries to the medical record should be made in a timely manner after the event to be documented by the relevant staff member. Any delay in the time of the event should be recorded. Other best practices include making objective comments, documenting any noncompliance, oral communications and informed consent, and stating objections regarding case management. The name and designation of person making the entry should be clear and their electronic signature must be included.
While EHRs are designed to ensure complete and accurate medical record keeping, physicians find data entry a hassle. Outsourcing medical transcription to a reliable service provider is a practical strategy to ensure high quality documentation.