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Explaining Proper Medical Record Documentation


Proper medical record documentation practices are learned skills.  Reasons for the lack of documentation include misunderstandings of what, when, how, and why to document.  Carriers and their hired “experts,” Peer Reviewers, generally deny provided treatment, testing, and durable medical equipment (“DME”) by exploiting the treating provider’s deficient documentation.  Doctors are often not held directly accountable[1] for deficient documentation and many providers may not understand the legal importance and potential consequences of improper or poor documentation.  Proper documentation provides countless benefits — examples include safety, effectiveness, and revenue — to the patient, the provider, and the medical profession as a whole.

From a New York No-Fault practical perspective, an insurance carrier may deny a provider’s reimbursement claims based on a lack of medical necessity.  An insurer must demonstrate the denied service(s) (treatment, testing, DME) were not medically necessary.  New York case law requires that in order to meet that burden, the insurer’s denial must be based on a peer review, IME report, or other competent medical evidence that sets forth a clear factual basis and a medical rationale for the denial.

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What Should Be Included in Patients' Records?

Peer review arguments routinely rely upon a treating provider’s documentation to demonstrate a lack of medical necessity.  Improper or limited documentation is a powerful argument for the carrier and their peer reviewers.  In order to guard against such an argument, it is advisable to include, at a minimum, a daily S.O.A.P. note:

  • objective and subjective testing/evaluation and the effect on treatment parameters and the adjustment to the patient’s treatment plan
  • the patient’s progress or lack of progress
  • treating observations
  • the details of discussions and consultations with the patient regarding need for more focused testing/evaluation, and any recommendations and reasons for prescribing DME
  • why there is an increase or decrease in office visits/treatment
  • any treatment milestones
  • start/stop times for procedures that require time-unit-based coding
  • specific testing was performed, read, discussed with patient
  • specific testing or DME was discussed, ordered, or fit for the patient

The Legal Importance of Complete and Proper Documentation

The legal importance of proper documentation cannot be understated.  Evidence of incomplete documentation:

  • may cause a perception that care was incomplete
  • may illuminate gaps in care and provide arguments suggesting poor critical care
  • may demonstrate trials of specific DME, therapies, or treatment protocols were not conducted
  • may establish testing was not medically necessary
  • may be used against the practitioner assisting the carrier to avoid payment claiming negligence or fraud
  • may allow the government to seek disgorgement of payments, impose penalties and fines, and exclude the provider from its program

Grossly incomplete documentation may result in professional discipline, lost revenues resulting from carrier denials of reimbursement (or delays during verification/EUO process), governmental action, poor coordinated patient care, improper billing, and a compromise to patient safety.

Accuracy, Completeness, Relevance and Timeliness

The four key elements to proper documentation are Accuracy, Completeness, Relevance, and Timeliness.

  • Accuracy:  Information will likely be relied upon by others and inaccurate entries could lead to improper medical advice.  One should not make entries for others.  Additions and corrections must be accomplished in the correct manner.  All patient statements that are recorded into the patient’s chart should be in quotation marks and accurately reflect the patient’s statement(s).
  • Completeness:  Blanks, gaps, and excessive spacing on a patient’s record should be avoided.  Do not start a new form until all lines on a prior form are completed or eliminated.  Use an appropriate “n/a” entry or complete all fields.  Travel cards, as a sole source of documentation are insufficient.
  • Relevance:  Do not use the record to speculate, gripe, blame, or complain, and avoid criticism of other professionals in a patient’s chart.  Avoid unsubstantiated subjective remarks.
  • Timeliness:  Entries must be made contemporaneously or as soon as possible after the event or observation.  Numerous laws, regulations, and policies have specific time limits for completion of entries.  The more time it takes to record the information, the less reliable the information.  Never make entries in advance, and never backdate entries.

Do not allow yourself to be stuck in old habits.  I wrote this article for you, not me.  Carriers, and more importantly the government and their auditors, rely upon improper and insufficient documentation to deny, and in the government’s case, to seek disgorgement of payments, impose penalties and fines, and exclude the provider from its program.  Proper documentation is not a suggestion, it is a mandate.

I am the General Counsel for a durable medical equipment company, and I provide a variety of services for my client, including prosecuting arbitrations and managing litigation.  That experience has illuminated to me the practical and legal importance of proper medical record documentation.

Disclaimer:  This article is for informational purposes only, and should not be construed as legal advice on any subject matter.  You should not act or refrain from acting on the basis of any content included in this article without seeking legal or other professional advice.  The content provided is general information and may not reflect current legal developments or address your situation.  This article does not create an attorney-client relationship between the reader and me.

[1] Secondary and down-the-line providers (MRI, DME, and Testing) often experience delays or denials in payment for provided services based upon the treating doctor’s lack of documentation.

Written by Scott M. Lupiani, Esq.

Scott spent time in private practice before becoming the General Counsel of Elite Medical Supply. Scott brings his vast experiences and thoughtful counsel into his legal analysis and decision making. Scott is an avid golfer and loves spending time with family and friends.