I’m back continuing simple Documentation Bytes; DOCBytes, for you to apply to your everyday world. The last post was so popular I thought it may be beneficial to provide a little more on EHR (electronic health record).
We have discussed key things to remember when documenting and learned that the quest for ease and simplicity through technology sometimes gets in the way. What we have longed for and wished for has become our “Trojan Horse” so to speak. Beautiful and powerful and yet, filled with surprise. Kind of like those new set of wheels; whether brand new or on its last leg; much awaited for and full of surprises; good or bad. Ultimately it is the goal of interoperability and lack thereof that can be the hindrance. The structured data we utilize isn’t quite good enough and the nonstructured data is even more difficult to decipher, extract, compile, share, and utilize in a meaningful way. Let’s just say, “You’re darned if you do and you’re darned if I don’t!!” Let’s go on to say, “You’re double-dog darned if you don’t focus on how we document and input data!!” Not only can you not extract the data you need for analytics but you also are potentially at increased risk for reduced payment and denial of payment with a poor story.
I often speak of free-text which can be limited in an EHR and also problematic when it comes to extracting and analyzing data. Many physicians I speak with choose to utilize dictation to further describe details they cannot record directly within the EHR such as when completing a daily progress note. As SOAP (Subjective, Objective, Assessment, and Plan) notes have gone to the wayside, for the most part, the 5Ws can help justify your outpatient visit or your 2 midnights to justify Inpatient. If you can speak to the bullets below you can create a better picture of the patient. Practice with a colleague; nurse, coder, clinical documentation specialist, or physician, you’ll see. As my colleague Bill Malm says; “If they don’t understand, the auditor probably won’t!” I will add we are seeing a revival of SOAP. Providers are realizing its relevance and importance in the overall revenue cycle. Isn’t it strange how we sometimes go back to the old after the new loses its luster? I frankly still love my husband and the 80’s. They never lost it.
- Be included in developing and updating EHR templates
- Give a complete picture of the patient stay utilizing SOAP or the 5 Ws
- Work with IT regarding what your data looks like when extracted/downloaded
- Utilize HIM professionals, CDI, and other colleagues to see how your documentation holds up or could improve
Keep the 5Ws of documentation in mind for documentation and medical necessity support.
- What are we treating?
- Procedure (if relevant)
- Where is treatment needed?
- Why is treatment needed?
- Why is this diagnosis acutely requiring attention?
- Relationship to chronicity; is this a chronic condition acutely requiring intervention?
- References to requiring testing, drugs, or other interventions
- References in variation from baseline to current state
- Potential for adverse outcome
- HoW are we treating it?
- What are we actively doing requiring the designated level of care or E&M services
- Implications if not performed
- When do you think they’ll get better?
- Expectation for stay/care plan
- Plan for discharge
5Ws of Documentation and Coding
These are helpful “DocBytes” to keep in mind to assist you in Excellent Documentation.
This work is licensed under
Sharon Easterling, MHA, RHIA, CCS, CDIP, FAHIMA