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Paying a price for poor documentation

Childers, Karen P. RN, MSN

HOSPITAL nursing

Find out how inaccurate or incomplete documentation can cause problems with reimbursement…and possibly with the law.

What you enter (or don't enter) in your patient's medical record affects more than his safety and care. During and after his hospitalization, reviewers from reimbursement agencies may scrutinize every detail. From their perspective, “not documented, not done” can mean the difference between proper payment and fraud charges.

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Paying by the rules

Medical insurance companies commonly require precertification for prescribed care before and during a patient's hospitalization. The hospital must send the agency information from the medical record and a precertification nurse or physician reviews it and authorizes treatment. After the patient is discharged, the nurse or physician compares charges against documentation in the medical record, so complete, correct documentation is critical throughout your patient's hospital stay. (Learn about the pitfalls of omissions in A lapse in documentation arouses suspicion.) Many health care facilities, insurance payers, and government programs use patient-specific clinical criteria to help determine whether a hospital admission is medically necessary. The criteria also help determine the appropriate care setting. The federal Centers for Medicare and Medicaid Services divides clinical criteria by body systems.

In many facilities, when a care provider wants to admit a patient, someone on his staff contacts the hospital intake department with the patient's clinical information and treatment plan. The intake nurse determines where to assign the patient and completes an admission review form. The hospital's reimbursement team sends the clinical data to the payer for precertification. If it's approved but the treatment plan changes, the altered treatment plan must be relayed to the payer before the hospital submits its bill.

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Fighting fraud

Fraudulent activity is a big concern in health care. The top billing areas under scrutiny are coding at a higher level of service than documentation supports, double billing, billing for services not rendered, and lack of medical necessity. Medicare periodically audits medical records after discharge to make sure admission was medically necessary. (For more information, see the National Health Care Anti-Fraud Association's Web site at When fraud is uncovered, the offender may be subject to stiff fines, criminal charges, or exclusion from the program. Added risks include bad publicity and a sense of distrust among patients.

Federal law mandates that health care providers establish a formal compliance program to help prevent mistakes and fraudulent activities. Your facility must adhere to the following rules:

  • Establish compliance standards and procedures.
  • Assign a compliance officer to oversee compliance.
  • Delegate compliance authority to clinical supervisors, physicians, and nurses to monitor and report violations.
  • Educate employees about compliance standards and procedures and consistently enforce them.
  • Use monitoring and auditing systems to detect criminal conduct.
  • Respond reasonably and appropriately to offenses.

The federal Office of the Inspector General recommends precautions to ensure an effective program, with accurate record keeping considered essential. You must accurately document your patient's care with pertinent facts, findings, observations, history, physical assessments, tests, treatments, and outcomes to ensure high-quality care.

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Charting styles differ, but safeguards don't

Regardless of the type of documentation you use, be vigilant in maintaining accurate medical records. For example, charting by exception lets you write narrative information only when patient information is outside the norm, but omitting information could have legal implications for you and your facility. The following example shows why you need to update your assessments several times each shift.

A nurse writes “WNL” (within normal limits) on the integumentary section of the charting-by-exception document at the start of his shift. Two hours later, the patient's intravenous fluid infiltrates, so the nurse removes the line and establishes a new one in a different site. However, he forgets to update the medical record to reflect the change in the patient's clinical status and his nursing interventions.

Computerized charting is becoming more prevalent. Although automation may save time, it doesn't relieve you of responsibility for including all elements of documentation in your nurse's notes: FACT (factual, accurate, complete, and timely) information.

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Doing it right

Nursing documentation that isn't up to snuff takes a toll on patient care, reimbursement to the facility, and the nursing profession. Regardless of the documentation style you use, follow all available guidelines to do it right and to ensure first-rate patient care.

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A lapse in documentation arouses suspicion

A patient has a hemoglobin level of 6.5 grams/dl (normal, 14 to 18 grams/dl). His clinical information is sent to the insurance company for precertification and his hospital stay is approved.

After he's admitted, a nurse picks up an ordered unit of packed red blood cells from the blood bank and takes it to the patient's room, but he refuses the transfusion. Heading back to the nurses' station, the nurse is called to an emergency and assigns a nursing assistant to return the blood. Caught up in the emergency, the nurse forgets to document the patient's refusal.

After the patient's discharge, his records indicate that a transfusion was ordered and a charge was generated, but no record of his receiving the blood or refusal appears in the medical record. If the record isn't corrected before billing, the hospital will be seeking payment for a service it didn't deliver. The payer may deny all or part of the payment or it could press fraud charges against the hospital.

Karen P. Childers is the clinical informatics coordinator at CJW Medical Center's Johnston-Willis Campus in Richmond, Va.

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Callison S. Securing insurance protection against fraud and abuse liability. Healthcare Financial Management. 53(7):50–51, July 1999.
Leeuwenburgh T. Fraud and Abuse Briefing for Health Care Compliance Officers. 12-Month Health Care Compliance Forecast 2000. Rockville, Md., Medicare Compliance Alert, May 15, 2000.
    © 2005 Lippincott Williams & Wilkins, Inc.