Standards of Documentation of Health records

Over the years, documentation standards have become more detailed and focused on patient care quality, appropriate reimbursement, and the prevention of fraud and abuse from a regulatory perspective. The Centers for Medicare and Medicaid Services (CMS) defines fraud as the intentional deception or misrepresentation that an individual knows, or should know, to be false or does not believe to be true, knowing the deception could result in some unauthorized benefit to himself or some other person(s) and abuse describes practices that either directly or indirectly result in unnecessary costs to the Medicare Program (CMS 2017). Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are priced fairly. (See chapter 16, Fraud and Abuse Compliance, for more discussion on fraud and abuse.) The application of the standards varies depending upon the content of the health record; whether the record is an inpatient, ambulatory, behavioral health, or physician office record; and from where the standards originate. Sources for standards include insurance companies and payers, government regulatory agencies, licensing boards, accrediting bodies, healthcare organization policies and procedures, and healthcare provider organization medical staff bylaws.

With the healthcare industry focusing on patient care quality, appropriate reimbursement, and the prevention of fraud and abuse, the goal of documentation standards is to ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient. This provides an inherent level of acceptable quality so other healthcare providers have a clear and accurate understanding of the patient’s condition and how the patient is responding to treatment. In addition, documentation standards drive appropriate healthcare reimbursement through accurate code capture during the revenue cycle process, reducing the chances that inaccurate or fraudulent claims are processed and sent to commercial or governmental payers for reimbursement.