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Making Sense (and Making Fun) of Medical Record Documentation

Adaptive Medical Partners | Healthcare Information

Making Sense (and Making Fun) of Medical Record Documentation

Growing up you might have been warned that any bad behavior would go on your permanent record; as a grown-up you’ve probably realized that was an empty threat used to encourage children’s positive behavior. There is no permanent record. Unless you count your medical record. A patient’s health information ideally is collected into a cohesive, chronological medical record that charts the good (the birth of a healthy child), the bad (a diagnosis of skin cancer) and the ugly (that awful rash). Across a person’s lifetime, multiple contributors will have some contact with the medical record. Below are some best practices for medical record documentation.

Correct Coding: If You’re Bitten by a Cow

For consistency across the global healthcare community, particularly for purposes of reporting mortality statistics, research or reimbursement, a universally-adopted set of codes is used to indicate diagnoses. Known simply as ICD-10, the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, is a medical classification list by the World Health Organization (WHO) that contains codes for diseases, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. The U.S. version of the list, the ICD-10 Clinical Modification, has more than 93,000 codes required by the Centers for Medicare and Medicaid Services and the National Center for Health Statistics.

The purpose of these codes might be serious (identifying causes of death or the reason for an injury doesn’t typically top lists of fun things to do), but some of the codes can be considered quite comedic. It’s good to know that if you’re ever bitten by a cow, there’s a code for that (W55.21). There also are codes for:

  • Pecked by a chicken (W61.33)
  • Burn due to water skis on fire (V91.07)
  • Hit or struck by falling object due to accident by canoe or kayak (V91.35)

The 10 Commandments of Medical Record Documentation

  1. The record shall be complete and completely legible. One of the main purposes of medical records is to communicate with other healthcare providers and with your future self who might not recall all the details. Handwritten scribbles or nonsensical abbreviations are not helpful to anyone. Plus, patients have the right to see the contents of their medical records; one day you might need to explain the meaning of some scribble.
  2. Each patient encounter shall include: date, reason, appropriate history and exam, assessment and care plan.
  3. All diagnoses shall be readily accessible for review.
  4. Reasons for and results of all tests shall be included. This includes x-rays, lab tests, diagnostic imaging, and other ancillary services.
  5. Relevant health risk factors should be identified. For example, include any self-reported health assessments.
  6. Patient’s progress shall be documented. This includes the response to treatment, change in treatment, or failure to follow the treatment.
  7. The patient plan for care shall include treatments, medications, referrals, education, and follow-up instructions. The plan should be specific, including dosage and frequency as appropriate.
  8. Documentation in the medical record shall support the intensity level of the patient evaluation. In other words, if a provider spends 15 minutes reviewing the patient’s history and another 15 minutes physically examining the injury, the medical record should be more than a sentence or two.
  9. All entries shall be dated.
  10. The codes reported on insurance claims shall be supported by documentation in the medical record.