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Top 10 Tips on Clinical Documentation

Top 10 Tips on Clinical Documentation. Ted Markgren, CO. What your chart says…. says a lot about you!. So, how is all that chart stuff coming along? Are you better? Are you worse? No change?. Are you a professional…. ….or are you a supplier?. Tip number 1.

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Top 10 Tips on Clinical Documentation

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  1. Top 10 Tips on Clinical Documentation Ted Markgren, CO

  2. What your chart says…. says a lot about you!

  3. So, how is all that chart stuff coming along? • Are you better? • Are you worse? • No change?

  4. Are you a professional…. • ….or are you a supplier?

  5. Tip number 1 • Are your clinical records organized? • Are the notes in chronological order? • Are there blank spaces between entries?

  6. Tip number 2 • Can you read your chart notes? • Do you know who wrote it? • Is it signed or co-signed by the clinician?

  7. Tip number 3 • Do you document communication with the referral source? • Does the dispensing script match the detailed script? • If not, does your chart support the change?

  8. Tip number 4 • Did you document your evaluation? • A diagnosis-specific clinical evaluation is a Medicare quality standard. • As a supplier you might “fill a prescription”, but as a professional, you will determine that the prescription is appropriate for the client.

  9. Tip number 5 • Do your records include detailed technical descriptions of the items or components provided? • Do your technical records match your clinical and billing records?

  10. Tip number 6 • Do your clinical records support and justify the items you billed? • Is the rationale for each component explained in the clinical record?

  11. …still on tip number 6 • Speaking of clinical notes… • … can another practitioner take over care based on your chart notes? • Is there a clearly defined plan of care? • Have all adjustments or modifications been recorded?

  12. Tip number 7 • Have you established expected goals and outcomes for the items or services provided? • This is a Medicare requirement! • Think pay for performance

  13. Tip number 8 • Did you document a final safety inspection of the item? • Did you record the torque settings? • Do you even have a torque wrench? • Limit your liability and exposure!

  14. Tip number 9 • Carefully document patient and family or caregiver education. • Is there evidence that you explained the precautions for use of the item? • Can you prove it?

  15. Tip number 10 • A follow-up plan must be included in the clinical record. • PRN is not always appropriate follow-up. • Did the follow-up appointment occur, or was the patient lost to follow-up?

  16. Be sure the chart reflects a professional image……YOUR professional image! Thank You

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