18 Nov Best Practices for Medical Record Documentation
Best Practices for Medical Record Documentation
Medical record documentation is essential both in and around the healthcare industry. Accurate, timely, and accessible records allow providers to deliver the best outcomes to patients. When issues arise, those same documents are what allow lawyers, insurers, and others to reach fair resolutions.
Below, we’ll define medical record documentation in greater detail and explain why it matters so much. Then, we’ll walk through what effective documentation looks like, how it’s used outside of medicine proper, what challenges can arise to complicate recordkeeping, and best practices for ensuring efficient documentation that allows a request and response process to be handled smoothly.
What Is Medical Record Documentation?
In the simplest terms, medical record documentation is a detailed accounting of a patient’s medical history and interactions they’ve had with healthcare providers. Medical documentation can include many types of medical records describing conditions, treatment history, test results, and context that medical professionals deem important. For example, information about a patient’s family history that’s relevant to diagnoses is often included in medical documentation.
Medical record documentation plays an important role in patient care, as it’s used to better understand afflictions, recommend treatments, and analyze outcomes, where parties may evaluate medical necessity for services or procedures. It also comes into play in other contexts, such as legal disputes and insurance claims. Lawyers, insurers, and other parties may depend on accurate medical records to fully understand their respective cases, which is why it’s important to obtain an authorized copy of records when needed.
To play these key roles, medical record documentation needs to be accessible. This is why professionals in many industries depend on effective medical records retrieval solutions. Today, advanced tools such as AI in medical records retrieval are increasingly being used to streamline access, improve accuracy, and reduce delays.
Why Medical Record Documentation Matters
Medical record documentation matters because it provides a clear record of what patients have gone through, which helps providers optimize their outcomes. It also ensures fairness, both during care provision and after the fact by way of legal or financial claims or challenges.
Healthcare experts at SCP Health highlight four reasons accurate documentation matters:
- Clear documentation facilitates communication between hospitals, healthcare providers, and patients
- Accurate and compliant documentation reduces risk management exposure
- Documentation covers quality indicators related to value-based care metrics
- Accurate medical records ensure appropriate and timely reimbursement
For these reasons, healthcare providers and other stakeholders need to keep their medical record documentation up-to-date and accurate. It also needs to be made accessible for swift and easy recovery, which is easiest when a communication infrastructure is in place and when access is limited to those who are authorized.
In other words, the act of creating accurate medical records is not the only part of the process that matters. Effective medical record documentation also needs to account for storage, maintenance, correction, and transmission of these records to impacted stakeholders.
Essential Elements of Effective Documentation
Effective medical record documentation generally looks the same in terms of its outputs, even if the processes used to generate it vary. Strong medical record documentation will ensure comprehensiveness and accuracy across the contents of records. Elements like patient demographics, provider notes, test results, and treatment details should all use the same scope and format across documents, irrespective of differences in patients’ cases.
Aside from this, data entry accuracy is key. Medical record documentation should feature accurate timelines, diagnostic codes, and progress notes for each case, ideally corroborated with relevant correspondence.
Beyond completeness, there’s a premium on objectivity and fairness in medical record documentation. Minimizing the extent of subjective interpretations and focusing instead on observable, factual matters reduces the likelihood and impact of pre-existing biases and prejudices.
With respect to process, there are fewer hard and fast rules. Any set of practices that ensures alignment with these critical features can be effective. By contrast, instances of inconsistency across a provider’s records may be indicators that a new process is needed.
Legal and Insurance Perspectives on Documentation
Aside from healthcare, two industries that are impacted heavily by medical record documentation are law and insurance.
- Law firms and attorneys depend on accurate medical records to establish case timelines and reliability.
- Insurers rely on documentation to make fair and timely decisions with respect to claims.
Professionals in both industries need strong medical record documentation to deliver the best results to their clients. When it isn’t there, negative healthcare outcomes can be compounded by poor legal and financial results.
How Poor Documentation Impacts Medical Malpractice
Poor medical record documentation is a major contributor to medical malpractice suits. In practice, this means healthcare providers looking to prevent these issues need to ensure better documentation across their staff whether defending a healthcare provider or pursuing the suit for a wronged patient.
Per a recent study on protection against malpractice, researchers found that issues with medical record documentation played a role in up to 20% of these lawsuits. But, despite the fact that inconsistencies can harm a provider’s defense and embolden attorneys to take up a case, few medical professionals receive impactful training on proper documentation.
The researchers go on to show that attention to detail, comprehensiveness, and a preference for unique inputs rather than overused templates can significantly reduce liability risks.
How Inconsistent Records Create Insurance Chaos
A 2024 study by The Commonwealth Fund shows how issues with medical records and miscommunications lead to unforeseen bills and coverage denials. Discrepancies in terms of what is or should be covered, what doctors recommend, and more have led to 45% of insured adults being charged for services they believe should have been covered.
With respect to practical impacts on both insurers and insured, about 40% of these instances led to successful challenges and reduced or eliminated payments. That share could be higher, as a majority of patients and doctors did not challenge. Additionally, a majority of patients experiencing denials noted a delay in care provision and eroded trust in the system.
Medical record retrieval for insurance companies can foster swifter and fairer provision of care, minimizing costly challenges, maximizing customer experience, and strengthening insurers’ ability to verify claims and defend legitimate coverage decisions
Common Challenges in Medical Record Documentation
Medical record documentation may seem straightforward, but there’s a reason it features so prominently in legal, insurance, and other disputes. It can be challenging to ensure accurate, consistent records due to time pressures and communication siloes between providers.
Returning to the malpractice study from above, the most common issues were:
- Incomplete documentation
- Inaccurate text records
- Transcription errors
- Judgmental language
- Altered documents
Another major challenge facing providers is the need to keep up with compliance standards and electronic medical record (EMR) systems. Whereas electronic health records (EHRs) are maintained across multiple providers, EMRs are specific to individual caregivers. This means they may feature idiosyncratic conventions that are hard to translate fully when expropriated.
As for compliance, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires safeguards for protected health information (PHI). Medical record documentation generally qualifies as PHI, so there are strict rules about how it can be shared and stored.
Best Practices for Maintaining Accurate Documentation
Given the critical role medical record documentation plays in healthcare, law, and insurance—not to mention patients’ and clients’ lives—following best practices is crucial.
A great first step for any healthcare professional is to become familiar with and make heavy use of all available guidelines. While the researchers in the study above warn against the overuse of templates, it’s still important to know what guardrails exist. To that effect, the Centers for Medicare & Medicaid Services (CMS) maintains a documentation matters toolkit that collects many useful resources in multiple accessible formats in one convenient location.
Beyond following official guidelines, practitioners should also prioritize clear, concise, and objective language across all documents. This minimizes the possibility of misinterpretation.
In addition, staff should receive training and education on medical record documentation practices. This should occur both during onboarding and at regular intervals throughout employees’ careers. Training modules should cover recordkeeping practices along with necessary compliance measures for storage, transmission, and reporting on issues.
Retrieval Partners: The Key to Fast Record Retrieval
Working with medical record retrieval services providers helps ensure that records are obtained quickly and efficiently, giving teams the timely access they need for thorough review and effective case preparation.
The benefits of working with a medical records retrieval partner include:
- Assurance that full record sets are in place before case or claim review
- Assistance with overcoming missing or incomplete medical documentation
- Support for meeting complicated compliance and/or security requirements
In addition, the best retrieval partners have robust communication networks in place, with pipelines that make securing and accessing documentation easier. This, in turn, significantly streamlines retrieval and benefits all stakeholders in the process.
Strong Documentation Strengthens Outcomes
Ultimately, sound operations in healthcare, law, and insurance all depend on effective medical record documentation. Effective records and recordkeeping practices can help deliver optimal health outcomes to patients and support swift, as well as fair conflict resolution whenever any issues arise.
However, despite these stakes, many potential challenges can lead to poor or inconsistent medical record documentation. To avoid these issues, medical institutions should implement best practices. Healthcare providers and other stakeholders should also consider working with medical records retrieval partners to streamline access to these crucial records.
For complete, compliant medical record documentation you can count on, partner with American Retrieval. We offer the fastest turnaround times, competitive rates, and a best-in-class HIPAA-compliant portal that’s easily integrated into your business’s existing operations. Book a demo today to experience the difference for yourself.
Sources:
Centers for Medicare & Medicaid Services. Documentation Matters Toolkit. https://www.cms.gov/medicare/medicaid-coordination/states/dcoumentation-matters-toolkit
The Commonwealth Fund. Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S. https://www.commonwealthfund.org/publications/issue-briefs/2024/aug/unforeseen-health-care-bills-coverage-denials-by-insurers
National Library of Medicine. Charting Practices to Protect Against Malpractice: Case Reviews and Learning Points. https://pmc.ncbi.nlm.nih.gov/articles/PMC9183775/
SCP Health. 4 Reasons Why Documentation is Important in Healthcare – ‘Think with your Ink’. https://www.scphealth.com/blog/think-with-your-ink-4-reasons-why-proper-medical-record-documentation-is-vital/
