Documentation in Skin Disease and Care- Proper documentation is important for several reasons:
- There is an ethical and professional obligation (failure to do so may lead to loss of hospital privileges and even, in extreme cases, one’s medical license)
- Allows support for billing at the appropriate level of service
- Poor documentation can result in lost income as Medicare and other insurers are paying more attention to documentation with random audits
- May help in the event of a potential malpractice claim (poor documentation will absolutely hurt the case); quality of documentation can determine a defensible malpractice case versus an indefensible one
- Best to document as if a Medicare claims examiner (or better yet, a plaintiff’s attorney) were reading the medical record over your shoulder
- Basic mnemonic for good documentation: LAWSUIT (legible, accurate, whole or complete, substantiated, unaltered, intelligible, timely)
- Important points in the medical record
- Do not leave blank areas in chart – if any blank areas, cross out so they cannot be used for out-of sequence entries
- If patient is noncompliant with medication instruction or advice, this should be documented (add verbatim quote from patient in quotation marks if appropriate)
- Document no-show or missed appointments and follow-up efforts to reschedule visits
- Always ask and document pertinent medical history (as this is a common factor in malpractice claims); case law reflects that it is not the patient’s responsibility to volunteer information, but the physician’s duty to ask appropriate questions
- If the medical record is copied, there should ideally be a dated recording of this
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