Health Record Content and Documentation
Health Record Content and Documentation
The saying “If it wasn’t documented, it wasn’t done (or didn’t happen)” succinctly conveys the level of importance all healthcare providers should place on health record documentation. Documentation is the recording of pertinent healthcare findings, interventions, and responses to treatment as a business record and form of communication among caregivers. Documentation takes various forms within the health record. Examples of health record documentation include progress notes, laboratory test results, radiology imaging reports, and operative reports, all of which provide a complete medical picture of the patient. The health record centralizes documentation regarding a patient’s healthcare visit and treatment history in an official, permanent, and recorded format. For thousands of years, individuals have been documenting stories and events in written form to share and reshare with future generations. Healthcare documentation is no exception. The health record, specifically the documentation maintained within it, has historically allowed and presently enables the patient’s healthcare providers to make well-informed concurrent treatment decisions for the patient and establishes a healthcare history for the patient for future reference.
It is important not only that there is documentation within the health record but that the documentation itself is appropriate, accurate, reliable, and readily accessible. Data quality is the reliability and effectiveness of data for its intended uses in operations, decision-making, and planning. Complete and accurate health record documentation drives high-quality patient care as well as appropriate coding and claims submission, resulting in appropriate reimbursement. Data quality applies not only to health record (clinical) information but also to billing and claims data, administrative and business data, and disease registry data. Documentation must be complete and accurate, support quality initiatives, and meet accreditation requirements. Chapter 6, Data Management, will address data quality in more depth.
When health record documentation is lacking in accuracy, reliability, and effectiveness, it may fail to appropriately describe the care and treatment of the patient. This lack of data quality can impact the quality of care the patient receives. Poor documentation impacts the assessment and evaluation of the patient and the communication among healthcare providers, results in medical errors, and contributes to poor patient outcomes. Poor documentation also impacts the accuracy of medical coding due to potential improper code assignment, resulting in inaccurate diagnosis and procedure codes. Inaccurate coding impacts billing, reimbursement, and claims submission for the care and treatment provided to the patient. If poor-quality documentation affects the accuracy of coding, billing, and claims submission, then state and federal regulatory compliance and accreditation standards of the healthcare organization can also be in jeopardy.
