The Documentation Story

Simplify the Documentation Story

Documentation may not be easy, but it doesn’t have to be complicated either, once you have mastered the learning curve. Many doctors get hung up on the “have tos” and do not take the reason behind them into consideration. We hear this when a provider expresses frustration over having to meet even the minimum requirements for documentation. Think about the elements necessary to meet these guidelines as the “what.” But what is the “why?”

Documentation, in its simplest form, is the story of what happened during a patient encounter being told so that even the busiest and most distracted insurance reviewer can understand it. This is the “why.” Like all good stories, it has a beginning, a middle, and an end – usually, though not always, a happy one. The more simply you tell this documentation story, the easier it is for any audience to follow and understand each patient encounter.

The Beginning, Middle and End

Your patient comes in to see you, presenting you with a complaint or issue. You ask the patient specific questions and learn subjective information. You examine the patient and gather objective information. Based upon this history and examination, you arrive at a diagnosis. Using your doctor’s thinking, you create a treatment plan with recommended services and goals for improvement. You treat the patient. They improve in measurable ways (or they do not, in which case, you revise your treatment plan).

When you read over your own notes, read them from the viewpoint of a complete documentation story. Can you easily understand, from what is written, what is going on with your patient? What happened to bring them into your office? What did you find out about them? What do you think about what you found? And what are you planning on doing to help them regain their pre-episode condition? Removing what you know about the patient, is it clear what you are treating the patient for and how they are progressing through care?

Looking at it this way, with documentation distilled to its most basic elements, it may be easier to see that if you skip over any element, your documentation story no longer hangs together. It’s like writing a story and leaving out the middle, or the full context. Each chapter of the patient’s story in your office should be an episode of care…with a beginning, a middle, and an end.

How simply can you tell your documentation story? The easier you make it on the reader, the lower your rate of recoupment and records requests. And, best of all, the more you will see revenue increase and follow up hassles decrease.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.