Common Medical Record Documentation Errors | Jane Jackson, RN, CRC | RxEconsult

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Common Medical Record Documentation Errors Category: Healthcare Administration by - January 3, 2017 | Views: 26939 | Likes: 0 | Comment: 0  

Documentation is not organized 

During a HEDIS or Risk Adjustment review, a progress note on a member can be separated from the entire chart.  This one progress note will have to be complete and stand on its own without any other documents.  There are several documentation templates often used in health care. 

  • CHEDDAR – chief complaint, history, exam, details of problem, drug/dosages, assessment, recommendations
  • MEAT – monitored, evaluated, assessed/addressed, treatment
  • PIE – problem, intervention, evaluation
  • SOAP – subjective, objective, assessment, plan

Documentation of conditions and diseases affecting a member should be clearly defined.  Do not use vague references such as:

  • consistent with
  • probable
  • possible
  • questionable
  • rule out
  • likely
  • suspected
  • suspicious for
  • working
  • borderline
  • pre-(??) such as pre-diabetic)
  • an up or down arrow
  • ICD-10 code only

Make sure to document current and co-existing conditions.  There are certain diagnoses that affect all aspects of a patient’s care whether it is choosing a cough medicine for a diabetic patient to a blood thinner for a patient with a history of a stroke.   Define a condition as acute or chronic as appropriate.

All factors complicating the care of a patient should be included in each progress note.  Use linking phrases to connect conditions that are interrelated to each other.  Linking phrases could include:

  • due to
  • because of
  • related to
  • associated with
  • secondary to

For the record, HISTORY OF means the patient no longer has this condition.  HOWEVER, there are many, many providers using this term regularly to express that the patient has a long history of.  A thorough review of the medical records or conference with the provider may be the only solution to this ongoing problem in documentation.  An exception to this is a History of Myocardial Infarction which is always to be documented in a patient’s medical record.   

Documenting a STATUS is crucial for medical records.  Status means the disease or condition is still present and affects the patient.  There are many conditions and situations where this documentation is imperative to an adequate overview of the patient and their health.  I recommend referring to HEDIS 2017, Chapter 2 and Risk Adjustment Chapter 7 by CMS (Center for Medicare and Medicaid Services) for more information in this.

If referring to a Problems List, Patient Demographics, Medication List or any other separate document, be very clear and direct.  To mention "See Medication List" will need a medication list somewhere in the chart with a corresponding date to match the progress note it is mentioned in.  It is not acceptable to mention, See Problems Lists yet the last Problems List on the chart is dated 2013.  There must be a clear connection between the progress note and the supporting document.

It is also a good idea to explain why a test was ordered.  The patient came in for a sinus infection but at the bottom of the progress note, there is an order for a chest x-ray and EKG.  Is there mention that the patient had a cough, pulmonary congestion, elevated heart rate, history of cardiac issues, recent heart attack, chest pain…  Why were the tests ordered?  There needs to be a clear connection between the assessment and treatment plan.


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