Documentation: The 30,000- Foot View

Documentation is an intrinsic component of every patient encounter. The financial success of a facility depends upon the completeness of the process. The major factor affecting the quality of an organization’s data (and therefore its revenue stream) is the accuracy of documentation. If you are not already convinced of the importance of accuracy in documentation, a study by the Centers for Medicare & Medicaid Services (CMS) found that of all of the improper Medicare benefit payments made during 2001, 43% were due to documentation errors. It is well known that patient quality of care is also related to quality of documentation. Furthermore, documentation is essential to meet the changing demands of regulatory bodies such as the The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Office of the Inspector General (OIG), and CMS.

The What and Why of the Medical Record
In the 19th century, the medical record was a sort of personalized lab notebook in which clinicians recorded their observations. In the 21st century, the medical record has many functions, including, serving as a basis for planning and documenting patient care, communicating among numerous health professionals, and protecting the legal interests of the patient and healthcare providers. The medical record may supply information for internal hospital auditing and quality assurance, documenting compliance with governmental regulations, and provide data for medical research. It is also a means of determining the billed revenue for physicians and hospitals. Thus, documentation must validate the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided. What is more interesting about today’s medical records is that they serve as a way of tracking the process of care not just for an individual patient, but for groups of patients in the form of benchmarking and clinical research.

General Principles of Documentation
This brief article cannot serve as an exhaustive resource on the legal or medical aspects of documentation. However, there are some basic principles. The medical record should be complete and legible. The documentation of each patient encounter should include the reason for the encounter and relevant history, physical examination findings and test results, assessment, clinical impression or diagnosis, plan for care, and date and legible identity of the observer. The patient's progress, as well as response to and changes in treatment must be documented. The billing codes reported on the health insurance claim form should be supported by the documentation in the medical record. Accepted methods for correcting errors and amending records should be used. While signatures are handwritten in paper documents, electronic records now support electronic signatures which append a statement such as electronically signed by after the clinician enters an assigned security code. Ethical principles pertaining to medical records are available from The American Health Information Management Association (AHIMA). Conduct which is not acceptable includes allowing patterns of retrospective documentation to increase reimbursement, misusing sensitive data or violating the privacy of an individual.

Physician Documentation
Evaluation and Management codes (E/M codes) used for physician billing are copyrighted and maintained by the American Medical Association. The payment system uses two sets of codes: ICD9 is used to identify the patient’s pathology (diagnosis) and support medical necessity; the Common Procedural Terminology (CPT) is used to code the physician’s treatment of that pathology (ie, the services provided). Payment is associated with different degrees of complexity of care based on key components. Each key component has four levels of difficulty. So, a physician using the 1997 Medicare Documentation Guidelines has 42 choices to consider, ultimately representing 6,144 possible combinations in order to select the correct E/M code (May 25, 2000 “Statement to the Health Task Force Committee on the Budget, United States House of Representatives, Medicare Regulatory Burden Imposed on Physicians,” www.acponline.org/hpp/hbstmt.htm). Electronic medical records systems, which automate this process, are becoming increasingly popular.

Hospital Based Outpatient
Wound Center Documentation
Outpatient wound center facility reimbursement for Medicare beneficiaries is defined by the CMS in the Hospital Outpatient Prospective Payment System (HOPPS). The HOPPS, published on April 7, 2000 in the Federal Register, was intended to revise the outpatient payment system for wound centers which were instructed to use three sets of five E/M codes: new patients—99201-99205; consults—99241-99245; and established/follow-up—99211-99215. Although CMS directed facilities to bill using all of these classes of codes, there were, in fact, only three payment groups. These are also known as Ambulatory Patient Classification (APC) Codes—610, 611, and 612. The Federal Register specified that each facility be expected to, develop a system for mapping the provided services furnished to the different levels of effort represented by the codes. Time, was readily adopted as a means of assessing the billed level of service. While easy to develop, a system based on a subjective assessment of time spent could result in healthcare workers justifying an inappropriately high-billed level of service compared to the actual work provided. In 2004, the American Hospital Association and AHIMA suggested to CMS that facility level of service be based on wound size, similar to the reimbursement model used for suturing acute wounds in emergency departments. An analysis of over 5,000 outpatient wound center visits, published in Ostomy Wound Management, proved this to be an unworkable method of achieving a reasonable distribution of charges due to the relatively small size of most chronic wounds. A method of measuring staff work was much more likely to yield a fair distribution of charges. CMS has yet to make a final decision on this matter but in the interval, most facilities have adopted various acuity scoring systems. These methods utilize a scoring sheet in which the point score tallied from various work elements tracks to a particular APC rate. CMS has emphasized that the ideal billing system would result in a normal distribution (ie, a bell curve) of clinic charges over a large dataset. Clinics must be wary of scoring systems which might skew charges to the right (towards higher levels of service). Furthermore, while the clinic charges might be calculated using a scoring tool, the tool itself is not sufficient documentation of the services provided. The medical chart must still contain all the elements upon which the score is based. This can create a compliance challenge for the facility, even if the scoring method is a sound one.

Documentation Unique to Wound Care
Author Note: The InStruction article describes in detail the type of documentation unique to wound care.
As physical defects, wounds have length, width, and depth. Undermining and tracts can be measured. The standard unit for measurement is in centimeters. The wound bed and the periwound skin can be described. Granulation, slough, eschar, and epithelization can be described and/or assessed in percent of wound surface area. Drainage can be classified by amount and character. Pain should be assessed. Dressing products must be documented. Documentation includes, the plans for the frequency of their change and the duration of these orders. Third party payers often have specific documentation requirements for the provision of medical equipment or dressing products. Debridement documentation requirements may include a description of the wound before and after the procedure, as well as the type of tissue removed (see the Fall 2007 issue of TWC). While this descriptive process sounds straightforward, it is not. Studies show tremendous variability among caregivers with regard to these documentation practices. These issues are not simple. Some documentation tools have been validated (eg, the BWAT and the PUSH tool).

It’s 10 am; do you know where you medical records are?
As the way in which we incorporate modern technology into medical practice evolves, our understanding of the medical record must evolve. Historically, the definition of the legal health record was fairly straightforward—it was the contents of the paper chart. With the advent of various electronic media, the definition of the legal health record has become more complex. It consists of the data, stored on any medium, collected and directly used in documenting services to an individual during any aspect of healthcare delivery. Some types of documentation may physically exist in separate and multiple paper-based or electronic or computer-based databases.
The HIPAA privacy rule requires that organizations identify their designated record set. As strange as it may seem, each facility must determine the specifics of the patient’s medical record. If one received a subpoena for a patient’s records, where would they go to get them? For example, in this issue photographs are discussed. How are photographs incorporated into the medical record? Does the custodian of medical records know where those photographs are kept if they had to be produced? Another example has to do with electronic databases. Unless the electronic database has been identified as the legal chart, the paper chart remains the legal chart. That means one still needs to print out copies of whatever is put into the electronic database so that the paper chart remains complete. It is best to define the legal chart before having to produce it, rather than after being asked to do so. Hospital records custodian can be a big help here, particularly since there are security issues involved. (For help, see the American Health Information Management Association, AHIMA, report, “Guidelines for Defining the Legal Health Record for Disclosure Purposes,” go to, library.ahima.org.)

Using Records for Benchmarking and Quality Assurance
Healthcare providers are expected to participate in continuous quality improvement. This means constantly examining practices to identify inconsistencies in patient care and look for opportunities for improvement. Thus, medical records provide important information about practice patterns on groups of patients, not just one individual. We can evaluate this through benchmarking. The American Productivity and Quality Centre (APC) provides a number of useful benchmarking guidelines, which are relevant to healthcare processes. The first step is for a clinic to know its own data, meaning that clinics must decide what parameters are relevant to its overall management goals. What parameters should staff follow? Healing rates, the number of patients in service after a certain number of days, the number of patients receiving a certain type of therapy, the revenue generated? Then if possible, a clinic must identify a HIPAA compliant way to compare its own data with that of other facilities. The APC has shown that companies that support benchmarking gain operational benefits and see higher financial paybacks in comparison to organizations, that do not. However, the process of benchmarking is almost impossible without some sort of computer technology.

Adopting Technology
The $1.7 trillion dollar US healthcare industry spends twice as much per capita as Scandanavia or Britain. However, the US has poorer health outcomes. One reason for this discrepancy may be slower adoption of electronic medical records (EMRs). Compared to other US industries, the healthcare system has been slow to effectively incorporate information technology into the work environment. According to former Secretary of Health and Human Services, Tommy Thompson “The most amazing thing about 21st century medicine is that it’s held together by 19th century paperwork.” The Computer-based Patient Record Institute (CPRI) stated that if providers continue with their current paper systems, they will lack the tools needed to manage the quality and costs of healthcare, the scientific basis for healthcare will continue to be undermined, and healthcare reform will be impeded.
What is slowing adoption of health information technology (HIT)? HIT is expensive and providers are uncertain as to the value they will derive for their investment. Furthermore, while doctors or hospitals are the ones who have to purchase HIT, as much as 80% of the potential healthcare savings accrue to insurers. And, like all technological advances, HIT is in a constant state of evolution. What if the system purchased today is obsolete tomorrow? What if it is not compatible with some system the hospital already has? For all of these reasons, clinicians find it difficult to decide how to incorporate technology into their practices. Nevertheless, electronic medical records are coming to every hospital, and to every clinic, one way or another.

HIPAA and the National Health Information Network
In 1996, Congress passed The Health Insurance Portability and Accountability Act (HIPAA). Its original purpose was to set a national standard for electronic transfers of health data, but Congress also saw the need to address growing public concern about the privacy and security of personal health data. The HIPAA Privacy Rule, issued by the US Department of Health and Human Services (HHS), became effective for most healthcare providers on April 14, 2003. The regulations are too broad to be discussed here but they have likely affected some aspect of every practice, particularly in how to handle access to your medical records. More recently, the situation got even more interesting. In 2004, President Bush issued an Executive Order requiring HHS to develop a national health information network (NHIN) within 10 years, overseen by a new HHS office, The Office of the National Coordinator for Health Information Technology. A number of bills have been introduced in Congress to speed the development of a national system of electronic health records.

So What’s a Clinic to Do?
Each wound center must critically assess their specific documentation needs. Not only must the mechanism of data storage be determined, but data retrieval must be determined as well. If paper is deemed adequate for individual patient records, then outcomes data and photographs will likely need to be managed by some other mechanism. Questions that follow will consist of: What information is important? How will it be kept? Who will keep it and how will it be used? Medical documentation, like medical care is a process and defining a system to improve your documentation might actually result in improving medical care for the patients.