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Why It's Important to Establish a Documentation Policy

Documentation is an essential part of any doctor's practice. It can improve quality of care, protect patients, meet regulatory requirements and improve efficiency and productivity.

Documentation is your primary defense mechanism in the event of a claim. It can be the reason a claim is filed or be your saving grace in preventing a claim. Documentation tracks and reports the care plan, treatment and compliance of the patient over time. It should also illustrate your contribution to providing a high quality of care to your patients and promote reimbursement from third party payers.

In the event of a claim, it is assumed the documentation was created at the time of care and that you documented what you did. After all, we have all heard, “If it’s not documented, you didn’t do it.” And I might add, “If it is not documented, you can’t bill for it.”

Your documentation should be legible, organized, accurate, complete, objective and timely. To consistently achieve these qualities from your entire staff, a policy on documentation is often beneficial. Consider a policy that addresses:

  • Legibility of all entries
  • Chart organization (e.g., allergies should be listed prominently, the most recent H&P easily accessible, etc.)
  • All entries must be dated and signed by the health care provider with their credentials
  • The timeliness of note completion 
  • Terms that are not permitted—those that misrepresent, exaggerate or understate objective facts
  • The prohibition of loose slips of paper and post-it notes 
  • The prohibition of unexplained, crossed-out entries, write overs or squeezed-in notes
  • The correct way to amend a record consistent with your record type (written or electronic)
  • How to handle an error noted by another healthcare provider
  • The need to avoid error-prone abbreviations and acronyms; use only appropriate terminology
  • Documentation of all electronic communications (texts, emails, etc.)
  • Scanning of documents for readability and completeness, including a timeline for maintaining paper copies 
  • A documentation procedure when EMR or paper records are not available 
  • Review and approval process of dictated and transcribed documentation 

If you have questions, please contact our Claims Advice Hotline

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