How to Train Your Dragon: Patient Documentation in the 21st Century

What’s one thing you never see on Grey’s Anatomy? A doctor sitting down at 3 am to dictate on a patient. Or write a note in their chart. I don’t even remember seeing a doctor on that show even look at a patient’s chart, let alone glean any valuable information from it. No one becomes a doctor because they love documentation.

But the reality is, whether or not you enjoy it, documenting on patients is one of the most vital aspects of treating them– and, of course, getting paid. Often, it’s the latter that gets a physician’s attention when it comes to completing their deficient documentation on patients.

Documenting on patients, however, is not as simple as stating “The patient had the thing, so I did the things.” It requires thought, consistency and at least half your attention. That being said, as a rookie doctor (and even as an overtired, overworked Resident) you will surely make a few mistakes.  Here are a few you should know– and avoid.

1. When you’re using a dictating program that transcribes as you go, like Dragon, make sure you’re speaking as clearly as possible. You have to train Dragon, and other voice recognition software, to understand your speech patterns. Furthermore, Dragon allows users to have their own profiles: this is what makes it magic. By only using your profile, you’re continuing to “teach” Dragon how to understand you. So, if you just hop in to whatever profile happens to be there (and it happens, trust me) not only are you not dictating to a profile that understands you, you’re messing up someone else’s voice profile.

2.  Hopefully modern technology and the advent of the EMR will make it less likely that you’ll dictate on the wrong patient, but there will be occasions when you dictate a complete hysterectomy on a male patient.  Generally, though, if you have a mile long list of op notes to dictate, sometimes, you’re going to pick Mr.Smith when you should have picked Mrs. Brown- the sooner you catch this mistake, the better. It can usually be corrected without much hassle, but if you are the type to “eat, dictate & leave” it may end up in the EMR on the wrong patient, and those who are charged with fixing it will spend the better part of the day hassling your office to try to figure out who had the hysterectomy– probably wasn’t Mr. Smith.

3. Ideally, your diagnosis shouldn’t be contradictory. Sometimes, though, it might come out that way, and in a shake of a lamb’s tail, some coder will come after you and demand you clarify. Don’t whine, or make excuses, or get defensive; just clarify. They can’t code it, and therefore it can’t be billed, if you are wishy-washy. You have to be very careful that you aren’t putting conditions on your problem list that contradict one another, your diagnosis needs to be fully supported by your documentation (if your patient has renal failure, your report should include labs and a history and physical that support this; if you just slap it on there at the end, and the patient has normal labs and came in with chest pain, that won’t go over too well.)

4. To you, it’s going to feel redundant and like beating a dead horse; but remember: the people who need it, the ones who are reading it, are seeing it for the first time. So be clear and to the point. Be accurate. You have to understand your purpose and your audience before you start. Your purpose is to be informative, accurate and concise. The next person to read it might be another doctor who is seeing your patient, it might be the coder who is trying to get it sent through for billing, it might be the patient themselves– or, it might be an attorney looking into malpractice.

5. Dictation is your best ally in the case of alleged malpractice. If a patient accuses you of doing– or not doing– anything, then your documentation of that patient’s treatment is the only thing that’s going to speak in a courtroom. And if you mess up in the first round of dictation and you only realize later, once someone wants to read it, that you made an error in what you said, if you so much as edit one item on that documentation, you’ll be accused of forging that documentation in your favor, which is arguably worse than getting it wrong  in the first place. Your account of your patient’s treatment is, of course, important for the patient’s continuity of care– but it’s also vital to the continuity of your career.

5a. You may or may not be aware that hospitals are getting audited by the Recovery Audit Contractors (RAC) and soon will be undergoing Medicare audits as a means for the government to take back the money that they’ve overpaid doctors in the last several years. RACs and Medicare request patient records from the hospitals so that they can nose around in them and sniff out any opportunities for them to take back money: either because it was assigned to the wrong Diagnosis Related Group (DRG) in coding, is deemed to be “medically unnecessary”, the care was provided in the wrong setting, or the documentation didn’t support the patient’s treatment when they were an inpatient. So, if you make Mr Smith an inpatient, you had better be able to justify that in your documentation, especially if his complaint is one of the most likely to be audited (chest pain). When the RACs are scrutinizing an inpatient account, what they’re really looking at is not if the treatment was medically necessary, but if that treatment really needed to be done in an inpatient setting. Though, the degree of understanding these auditors have of medicine and medical coding is arguably limited, and this is why it’s all the more important that you document very clearly and consistently.

So, are you ready to train your Dragon?

BHM Healthcare Solutions is a healthcare management consulting firm whose specialty is optimizing profitability while improving care in a variety of health care settings. BHM has worked both nationally and internationally with managed care organizations, providers, hospitals, and insurers. In addition to this BHM offers a wide breadth of services ranging including healthcare transformation assistance, strategic planning and organizational analysis, accreditation consulting, healthcare financial analysis, physician advisor/peer review, and organizational development.