The Cost of Documentation Deficits

By Pat Wilson, RN, AAPC

Improvements in the quality of healthcare and rising healthcare costs have recently led to an increased focus on cost containment and its strong relationship to effective nursing documentation. When it comes to clinical documentation, the rule is simple: If it is not documented, then it is not done. In order for a healthcare facility to have financial success, accuracy in documentation is a must. Reimbursements from payers – including insurance companies and government agencies – are wholly dependent on a patient's medical record, and what information is recorded there.
Before claims are sent for reimbursement they are randomly selected for an internal audit to review accuracy. Once sent to the payer, charts and Electronic Medical Records are also randomly audited. If they are not coded correctly or do not show medical necessity, then the claim can be denied and no reimbursement issued. Each reimbursing facility also requests claims to be submitted per their specific payer regulations and claimants must conform to rules released by the American Medical Association, Medicare, and Medicaid in order to receive reimbursement.

In addition to poor or inaccurate documentation, significant financial losses can result from missed notations. A simple example of how this can occur is illustrated in the following scenario: As Nurse Nancy begins her shift she receives her assigned patients, stuffs a handful of Normal Saline Flushes into her pocket, and starts rounds. During an assessment she flushes IV access to ensure there is a working site in case of an emergency, completes her assessment, and moves on to the next patient. If Nancy does not specify the flush in her documentation, the Medical Coder will not capture the cost of the flush when the file is reviewed and the facility will not be able to recoup this loss. Multiply this instance by several patients a day, and for other nurses in similar situations, and a healthcare facility is suddenly facing a significant loss of reimbursement.
According to the American Nurses Association, nurses are key players in the reimbursement process and are encouraged to avoid documentation pitfalls by following a few basic rules:

• Timely documentation: Document nursing interventions as soon as possible after the completion of the nursing activity.
• Avoid gaps in the documentation record: Never leave a space to add additional notes at a later time. Rather, follow your facility’s policy and procedures for late entries, and include a reason for a late entry.
• Avoid bias and refrain from including personal opinions in the record: Documenting personal comments may indicate a bias against the patient and his care. Examples of labeling include using words such as obnoxious, belligerent, hostile, or rude (Austin, 2006).

Good nursing practice requires accurate and detailed record keeping. Complete, timely, and accurate documentation goes a long way in ensuring that nursing interventions are compensated, so that employers recognize the added value of nurses as a whole and healthcare costs can be managed more effectively (Gugerty et al., 2007).

To learn more about professional standards for documentation, check out RN.com’s six contact hour CE course, Professional Documentation: Safe, Effective & Legal.

American Nurses Association (2010). ANA’s Principles For Pay For Quality. Retrieved from: http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Priority-Issues/ANAPrinciples  

Austin, S. (2006). Ladies of the jury, I present... the nursing documentation. Nursing 2006, 36(1), 56-64. Retrieved from: http://www.nursingcenter.com/pdf.asp?AID=622073  

Gugerty, B., Maranda, M.J., Beachley, M., Navarro, V.B., Newbold, S., Hawk, W., et al., (2007). Challenges and Opportunities in Documentation of the Nursing Care of Patients: A Report of the Maryland Nursing Workforce Commission, Documentation Work Group. Retrieved from: http://www.mbon.org/commission2/documenation_challenges.pdf
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Pat Wilson, RN, AAPC, has been with American Mobile Healthcare, an AMN Healthcare company, since 2000.