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Set the Record Straight On Documentation

      Doctors, young and old, need to document information in the patient's record. Many physicians have some knowledge of the process but have not learned the art of what needs to be included and what really should not be a part of the permanent record.
      As mentors, experienced medical directors have a great opportunity to save a young physician doing the documentation a great deal of time, pain, and embarrassment by teaching him or her what should and should not be included.
      For example, condemning statements written to make the author “look good” will surely be questioned and usually will have the opposite effect. Notes that contain hearsay or statements that have not been confirmed by the author are just trivia and do not contribute accuracy to the records. Likewise, opinions not based on fact have no place in the medical record. That is what the legal community refers to as “finger pointing” and will cause nothing but trouble. Seasoned documenters can embellish on this subject of what should not be written as you mentor young physicians.

      What Should Be Included

      The resident physicians are really taught well what needs to be in the history and physical (H&P). For long-term care, they should include statements about the patient's ability to hear, speak, see, chew, and swallow. Ambulation skills, continence, skin challenges, and mental skills including reasoning are important geriatric specific notes that the trainee can add to make the H&P more site specific.
      In addition to the chief complaint, include the reason why the patient is in your nursing home. This supports the initial certification process and, if challenged, there will be no payment denials.

      Noted Challenge

      The progress note presents the greatest challenge. Handwritten notes must be legible. If so, they are totally acceptable. Otherwise, dictate or type the notes. Eventually, electronic medical records should solve this problem, but that is another subject.
      The format for the progress note depends on individual preference, but CMS still prefers the S.O.A.P. process. The note must conform to the billing code and contain facts addressing the current problem(s) and relationship to past conditions and current changes.
      This sounds like a lot, but seasoned documenters include only the pertinent facts. It really is not that difficult. Carefully chosen words reflecting your genuine caring feelings for the patient's problems go a long way in front of a compassionate jury.
      Now for a “pearl” that the physicians I train say is the most important thing they learn during their geriatric rotation: Insist that any changes made in the treatment plan—or any specific test result that is not going to be addressed—be documented. And use the word “because” in stating your reason for what is done or not done.