Ensuring Clinical Documentation Integrity and Avoiding Common Pitfalls Across the Continuum of Care

In recent years, changing factors in the healthcare landscape, such as the use of electronic health records (EHRs) and new reimbursement methodologies, has led many healthcare organizations to begin focusing on the quality of documentation in health records across the continuum of care, in both inpatient and outpatient settings.

The act of documenting in the health record has become a challenging task for providers in all types of settings. Many providers struggle to document in a format that helps to accurately report all outpatient visits, including other evaluation and management (E/M) services and inpatient encounters. In addition, the use of copy-forward/copy-paste functionality within the EHR and the many different payer documentation requirements often create issues for many organizations and providers. Issues include provider burnout and an increase in billing denials related to lack of documentation and/or clinical indicators.

The primary purpose of health record documentation is to facilitate communication among providers to ensure continuity of patient care. Documentation serves a multitude of other purposes, as well. The integrity of the documentation is crucial because the health record is also a legal record. There is a significant need for providers to understand what they should be documenting and why it is important to document accurately and to the highest level of specificity, which ideally fulfill requirements like coding and quality reporting.

It can be helpful to understand common barriers to quality documentation in both the inpatient and outpatient setting so that providers can successfully combat the complicated documentation nuances across the care continuum.

The Building Blocks of Quality Documentation

Regardless of the type of healthcare setting, quality clinical documentation has the following seven characteristics.¹ It is:

• Legible: The reader should be able to read and comprehend what is documented.
• Clear: Documentation should not be vague and should fully describe what is wrong with the patient without being open to interpretation.
• Complete: The documentation in the health record should completely address the patient’s issues and/or concerns from a diagnostic perspective (e.g., chief complaint/reason for visit, working diagnosis, final diagnosis, etc.). In addition, the documentation contains the proper authentication by the provider (signature and date).
• Consistent: Documentation should not be contradictory between the providers and/or from one progress note to another.
• Precise: The more detail a provider documents in the health record, the more information will be available to ensure the accuracy of the clinical documentation in the health record.
• Reliable: Is the treatment plan supported by the provider documentation in the health record?
• Timely: For the best care and treatment to be rendered, the timeliness of the clinical documentation entries is very important.

Providers in both the inpatient and outpatient settings often use one of the following formats when documenting their clinical notes:²

• SOAP (Subjective, Objective, Assessment, Plan): This is the traditional problem-oriented note format, created to allow providers to document the clinical encounter in the same sequence in which it occurred.
• APSO (Assessment, Plan, Subjective, Objective): This format, similar the SOAP note, presents the Assessment and Plan before the Subjective and Objective sections, has grown in popularity with the evolution of the EHR.

Common Documentation Pitfalls

With the adoption of EHRs, many providers argue that the sheer length of the clinical notes makes it difficult to locate what they often see as the most pertinent information—the integral assessment and plan components. This “note bloat” can generally be traced to the ability to copy and paste in the EHR. Therefore, many providers opt for the APSO format because it places at the top of the note.

Unfortunately, using the APSO format does not eliminate the inappropriate use of copy-paste/copy-forward or note bloat results. In a way, APSO can create the false perception of being more efficient for some providers just because they are spending less time reviewing charts. But the reason for that reduced amount of time spent reviewing charts is that many providers now only read the top of the note to obtain the most pertinent clinical information, neglecting the subjective and objective sections.

Of course, it is important for providers to review all documentation located in the subjective and objective sections; these sections help to paint a full picture of the patient’s clinical picture. Furthermore, these areas may impact the coding and reporting of the services rendered. Nevertheless, all clinical documentation in both the inpatient and outpatient settings should be validated by the provider performing the data entry to ensure that the most accurate clinical picture is captured in the patient’s health record, and to the highest level of specificity.

Inpatient vs. Outpatient Documentation

What is the major difference between inpatient and outpatient documentation? The main differences are in the reimbursement methodologies. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is used to report diagnoses in all healthcare settings, with different coding guidelines that apply specifically for inpatient encounters and specific coding guidelines related to outpatient visits. For example, uncertain diagnoses documented as “suspected,” “probable,” “rule out,” and similar terms demonstrating uncertainty can be coded and reported in the inpatient setting, whereas the same terminologies are not reportable in the outpatient setting.

Following is an overview showing which sections of the ICD-10-CM Official Guidelines for Coding and Reporting apply in which setting or settings:³

Providers are reimbursed for their professional services based on E/M codes. Here is a quick overview of the documentation requirements related to E/M services.⁴

Organizations can deploy certain activities that will help ensure documentation and data integrity in both the inpatient and outpatient settings. Provider education across the continuum of care is important. Providers should be educated on the different reimbursement methodologies to ensure they have a full understanding of how their documentation translates into reportable data. The impact of their documentation will also vary depending on the healthcare setting.

Education should be performed by health information management/coding and clinical documentation integrity professionals because of our wealth of knowledge of the documentation requirements for coding and reporting. Education may also include topics such as how to accurately leverage EHR functionalities to reduce the burden on providers.

Notes

1. Combs, Tammy. “The Importance of High-Quality Clinical Documentation Across the Healthcare Continuum.” Journal of AHIMA April 1, 2020. https://journal.ahima.org/the-importance-of-high-quality-clinical-documentation-across-the-healthcare-continuum/
2. Shoolin, JS. “Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation.” Applied Clinical Informatics. June 26, 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3716423/#:~:text=We%20describe%20a%20note%20format,note%2C%20making%20provider%20search%20faster.
3. “Practice Brief: Evolving Roles in Clinical Documentation Integrity – A Provider’s Guide to the Art of Documentation.” Journal of AHIMA. July 10, 2020. https://journal.ahima.org/practice-brief-evolving-roles-in-clinical-documentation-integrity-a-providers-guide-to-the-art-of-documentation/
4. Ibid.

Anny Pang Yuen (anny.yuen@apconsultingassociates.com) is a principal/independent consultant at AP Consulting Associates LLC.