What do those working in Utilization Management, Denials and Appeals, and Clinical Documentation Integrity have in common? They along with many others, are reliant upon the physician documentation within the medical record. There are many adages such as “if you didn’t document it, you didn’t do it,” and “think in ink.” However, there is little discussion about what elements are necessary for good documentation.
This is not a sensationalized statement, but instead, reflects the daily reality seen by those working within healthcare. Over the last several years, there has been a perfect storm of events leading to the current situation, where it can often be said that the physician documentation is no longer a useful source of information regarding the patient encounter. The bright future of the electronic medical record has been replaced by the nightmare of note cloning, auto-population of extraneous information, nonsensical statements due to voice recognition software, and the ongoing misuse of generic templates.
There are many factors that have brought us to the current state of affairs, and the goal here is not to blame technology for a medical record that is on life-support. After all, the tools that we’ve been given cannot be blamed for how we decide to use them. A detailed discussion of the benefits and failures of the EMR itself, falls outside the scope of this post. Here, we will focus primarily on the documentation of clinical care (e.g. physician progress note).
Whether writing notes, or reading them, the 7C’s provide a framework to understand what makes a document strong or weak. This may be used as a positive feedback loop, to continue the process of improving communication. Make it a habit to review all clinical documentation from the perspective of the 7C’s.
The 7C’s for documentation include: COMPLETE, CONCISE, CORRECT, CLEAR, COMPLIANT, CONSISTENT and CODABLE information.
When reviewing clinical documentation, it’s useful to think in terms of how well the documentation meets the 7C’s. Medical records that are strong in all 7 elements, should be considered the standard we expect of the treatment team. Sadly, despite the common sense nature of these criteria, this level of documentation is rare. We all struggle with operating efficiently, to provide good and compassionate care, while trying to meet a dizzying amount of regulatory requirements. Having clear communication + documentation skills can provide for better care, decrease the burden of documentation, improve operations + so much more. In the ever-changing landscape of healthcare, it’s especially important to optimize what’s within our power + control.
In keeping with the mission of JBH Solutions, we provide real-world interventions and solutions that can be implemented quickly, with minimal resources. Having a checklist for what effective + constructive documentation should include for optimal communication of patient care is a start to building quality data. Here’s a handy visual + boxed checklist to keep around as a reminder – print it, share it, spread it, make use of it + please do apply it! Your bottomline will thank you.
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