For decades now, hospital leaders have observed connections between quality of clinical documentation and revenue health. While progress toward improved clinical documentation has certainly been made in that time, most hospitals and practices are still missing out on a significant percentage of revenue due to documentation issues and related increases in denials. In this blog post, you’ll learn common missteps we’ve seen in documentation lately, reasons to invest in improvement efforts, and best-practice strategies for transforming clinical documentation practices at your organization.
Common missteps in documentation
Errors in documentation often lead to denied claims or “downcoding,” both of which can translate into significant financial losses. These errors span a broad spectrum of frequency and effect, but the following six are the most common and critical mistakes we’ve seen your peers making in documentation.
There are errors in content:
- Incomplete: Documenters must include all relevant details about demographics, medical history, SDOH, and present illness. If the report is not finished, the claim will likely be denied, or reimbursement reduced.
- Inaccuracies: Transcription errors, outdated information, and clinician communication issues are all understandable mistakes that can all, unfortunately, lead to inaccurate reports. A more extreme form of inaccuracies is fraudulent billing practices (‘mistakes’ are intentional).
- Lacking clarity and specificity: Medical documentation must be clear and concise as well as descriptive and comprehensive. Reports must toe a thin line of including enough but not too much, and often, brevity is prioritized over thoroughness.
And there are errors in process:
- Lacking documentation of patient consent: With very few exceptions, patients must consent to medical treatments and procedures prior to receiving them. If these consent conversations are not completed and documented, hospitals can suffer legal and financial consequences.
- Lacking authentication: Missing or incorrect dates and clinician signatures within charts also puts organizations at a higher risk for legal issues.
- Illegible: Complete and thorough documentation won’t be worth much if no one can understand the handwriting or terms/abbreviations used in it. Misinterpreted or indecipherable information can lead to serious breakdowns in communication and errors in clinical decision-making.
Top reasons to invest in documentation improvement
There are many benefits of excellent documentation – the primary one is reducing the amount of precious time and limited resources practices spend on denials management and/or litigation. Others include:
- Increased reimbursement: When documentation accurately reflects the severity, complexity, and medical necessity of care, it supports appropriate code assignment, reduces claim denials, and helps maximize reimbursement.
- Compliance and audit readiness: Effective documentation practices ensure compliance with coding and billing regulations and reduce the risk of fraud and abuse. By capturing the necessary information and ensuring proper documentation standards, healthcare organizations are better prepared for audits and can provide supporting documentation to validate services rendered.
- Improved safety and outcomes: The reality of relying on each other for thorough and detailed documentation creates a culture of collaboration and communication among clinicians. Thorough, comprehensive documentation practices also reduce risk of medical errors and support high continuity and quality of patient care.
- Enhanced care coordination: Accessible documentation is key to advancing interoperability, facilitating seamless care coordination, enabling the sharing of critical patient data, and helping healthcare providers make informed decisions regarding treatment plans and interventions.
- Data and metrics: Hospitals need reliable data to assess quality metrics and performance. Documentation is a key part of this data, as it provides a basis for identifying clinical, operational, and financial roadblocks, setting related goals, implementing evidence-based practices, measuring progress, and adjusting accordingly.
- Increased efficiency and workflow optimization: Investing in documentation improvement processes, such as electronic health records (EHR) systems and templates, can streamline extensive documentation workflows and reduce administrative burden. Well-designed documentation processes enhance efficiency, allowing healthcare providers to spend more time on direct patient care and less on administrative tasks.
- Risk reduction: As mentioned prior, superior documentation can protect healthcare organizations in the event of legal disputes, malpractice claims, or allegations of negligence. In fact, documentation records can provide crucial evidence to support the organization’s position and reduce potential legal and financial risks.
- Research advancement: Consistent and standardized documentation practices enable healthcare organizations to participate in research initiatives, clinical trials, and population health management, contributing to advancements in medical knowledge and improving patient outcomes.
Documentation improvement is a strategic investment that aligns financial, clinical, and regulatory objectives while supporting providers’ overall mission of delivering high-quality care.
Proven strategies to strengthen your documentation practices
There are several opportunities for documentation improvement that hospitals and groups of any size, location, and population can readily implement. When deciding what strategy(ies) to focus on first, consider what your organization struggles with most, how big your budget and resource pool is, and what changes will give you the most impact.
- Prepare clinicians: Don’t wait for mistakes to start happening; proactively train anyone involved in documentation. Upon or before hire, physicians, nurses, and other healthcare providers should be educated on the importance of and process for accurate and detailed clinical documentation.
- Standardize processes: Implement consistent documentation protocols and templates to ensure consistency in communication patterns and care planning across clinicians and sites of care. Standardizing documentation helps reduce care variability and improve patient outcomes.
- Emphasize documentation integrity: Offer ongoing support for preserving integrity and accuracy in clinical documentation. Support could include traditional routes—advanced training, regular audits, or one-on-one feedback sessions—or it could entail using artificial intelligence (AI) to analyze and identify potential documentation mistakes.
- Consider clinical decision support (CDS) tools: CDS emphasizes its incredible utility by reliably delivering the right information to the right people through the right channels (typically EHR) in the right format at the right points in the workflow. This best practice framework helps clinicians improve accuracy and efficiency in documentation—critically avoiding delays and/or denials.
- Recognize documentation champions: Notice and value all contributions to excellent documentation made by staff and clinicians. In many cases, incentives or rewards can be meaningful motivators for teams to continually advance their documentation skills and consistently demonstrate excellent documentation practices.
- Stay tuned into local, state, and federal developments: Remain informed about changes to coding and documentation guidelines and requirements issued by CMS and other regulatory bodies. Regularly update education and training programs to ensure documenters understand the meanings and implications of changes.
Our passionate, dedicated teams at Resolv have been helping healthcare organizations optimize documentation—and each other unique component of the revenue cycle—for over 30 years. Drawing on deep industry expertise and simple, powerful technology, we’ll design specialized solutions for you to best fit your objectives and improvement opportunities. Book a consultation to reimagine the revenue cycle with us.