Practice Policies: Establishing a Documentation Policy

The purpose of your policy manual is to ensure a consistent approach to common situations that may be experienced in your practice. The policy and procedure manual should be a living document that is reviewed and updated periodically. All staff should review and acknowledge their understanding of the practice's policies annually.

One area your policy manual should address is documentation. Documentation is your primary defense mechanism in the event of a claim. It can be the reason a claim is filed or be your saving grace in preventing a claim. Documentation tracks and reports the care plan, treatment and compliance of the patient over time. It should also illustrate your contribution to providing a high quality of care to your patients and promote reimbursement from third-party payers. 

In the event of a claim, it is assumed the documentation was created at the time of care and that you documented what you did. After all we have all heard, “If it’s not documented, you didn’t do it.” And I might add, “If it is not documented, you can’t bill for it.”

Your documentation should be legible, organized, accurate, complete, objective and timely. To consistently achieve these qualities from your entire staff, a policy on documentation is often beneficial. Consider a policy that addresses:

  • Legibility of all entries
  • Chart organization (e.g., allergies should be listed prominently, the most recent H&P easily accessible, etc.)
  • All entries must be dated and signed by the healthcare provider with their credentials
  • The timeliness of note completion 
  • Terms that are not permitted—those that misrepresent, exaggerate or understate objective facts
  • The prohibition of loose slips of paper and post-it notes 
  • The prohibition of unexplained, crossed-out entries, write overs or squeezed-in notes
  • The correct way to amend a record consistent with your record type (written or electronic)
  • How to handle an error noted by another healthcare provider
  • The need to avoid error-prone abbreviations and acronyms; use only appropriate terminology
  • Documentation of all electronic communications (texts, emails, etc.)
  • Scanning of documents for readability and completeness, including a timeline for maintaining paper copies 
  • A documentation procedure when EMR or paper records are not available 
  • Review and approval process of dictated and transcribed documentation 

If you have questions about documentation policies, please contact us.

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