Years ago, when clinical documentation improvement programs first appeared as "DRG Optimization Programs", I heard a consultant describe the issue that most hospitals faced as one of "underdocumentation" by physicians.
At the time, I thought it sounded like an incredibly ingenious way to hook a client on the concept of optimizing payments by impacting the way physicians documented in the patient record. A decade and many OIG settlements later, I still find myself pondering the concept of underdocumentation and what it means, exactly. I even address the issue in A Compellng Case for Clinical Documentation - where it is more appropriate to discuss documentation in a complete context. In otherwords, if there is such a thing as underdocumentation, then there must also be it's polar opposite: overdocumentation.
Some of this phemonena we have seen in physician office documentation, where even though a patient only received and/or needed a level 2 intervention, the physician documents enough to support (or at least thinks it supports) a level 4 intervention, so the higher fee can be charged to the insurance company or the patient. But do physicians ever really "overdocument" in the inpatient setting?
If the definition of underdocumenting is: "documenting that less was done than was actually done, or documenting less about a patient's condition than what is supported clinically", then, the definition of overdocumenting must be: "documenting that more was done than was actually done; or documenting more about a patient's condition than what is supported clinically". It seems improbable that a physician would document more about a patient's condition than was is supported clinically - unless of course, as many physicians in the late 1990s and early 2000's told the OIG: "I documented it because the hospital told me to document it that way." So, it seems that when we define documentation as being prone to either overdocumentation or underdocumentation, the issue of compliance is a very real, and significant one.
The conclusion I have reached is this.....documentation is best governed by a set of objective criteria like the 7 Criteria for High Quality Clinical Documentation. If we simplify its content by limiting our descriptions to words like over and under documentation, then we open the door for significant problems with the root cause being documentation that is gauged to achieve a certain end. We also tie the essence of the documentation to reimbursement - which is an unfair simpliciation of the importance of clinical documentation. By applying the 7 objective criteria of legible, complete, clear, consistent, reliable, precise and timely, we provide a framework for clinical documentation that ensures that the data generated by the healthcare organization is infact an accurate representation of the care provided to patients.
