September 2017 Medical Oncology News
Back To Basics
When documenting, we all strive to provide supporting documentation for each process. In doing so, sometimes we fail at the basic requirements. We get so caught up in detailing each and every step; listing how many catheters, what type of imaging was utilized, who was present... that we forget the basic information such as: patient's name, identifying factors, date of service, etc.
The Electronic Medical Record should help to eliminate these types of errors by utilizing the available tools and system functionality, but if the beginning process is incorrect, errors can and will occur. The initial creation of an electronic template is a crucial time. Take time to ensure that everything is correct before implementation. Does the document clearly state the date of service? Does the document allow for required elements for the corresponding procedure? Does the document include the required components for an electronic approval or signature? These are some questions to consider when creating an accurate, easy to use document.
It is recommended to utilize a standard format when developing electronic forms and templates to ensure required elements such as dates, patient identifiers and electronic approvals are consistent for all users and procedures. It is further recommended to gauge accurate use and completion of the documentation by the intended users once the document has been implemented. Timely identification and correction of documentation issues may prove to be beneficial in the event of a payer review and could provide improvements in the quality of documentation available for other providers and clinicians.
To be certain that your practice and facility have the required documentation elements and the medical record supports the services billed, Revenue Cycle Inc. recommend a comprehensive medical record review. For more information on our consulting services, please contact us here or 512-583-2000.