Here is a case study for your consideratiion: An academic medical center on the East coast employed all physicians affiliated with the system and the hospital. An audit of the physicians’ office notes revealed inconsistencies between the documentation in the record and the level of the bill that was generated. Physicians were adamant that their patients were all very complicated and that, even though the documentation did not support a level 4 visit, they had in fact, performed a level 4 visit. The organization was concerned about the findings, but the bigger question was, “what can we do to ensure that the documentation is reliable – in other words, that the documentation reflects what actually occurred during the visit?”
The organization decided to measure and improve clinical documentation accuracy through physician shadowing, a process that would ensure the reliability of the documentation. This process required that an expert in clinical documentation would be present during the physician office visits with patients to observe the interaction between the physician and the patient. The documentation expert would record in writing the interaction between the physician and the patient. Since patients at the academic practice were used to residents observing their visits, they did not mind being observed by the documentation expert during the visit.
At lunch and at the end of the day, the documentation expert met with the physician to compare the documentation the physician provided in the patient record with what the documentation expert had observed and recorded. In most cases, the physicians were doing more and saying more than they were documenting. Common omissions included viewing x-ray results. On 14 occasions, the physicians reviewed x-ray results and discussed the results with their patients. However, during only one of those occasions did the physician actually document that he had reviewed the x-ray. This activity, viewing an x-ray in addition to discussing it with the patient has an impact on the level of visit that the physician can bill. In the majority of the cases, the physicians were providing higher services than they were documenting. The physicians felt venerated and also grateful to the administration who arranged with them to perform the documentation study.
More importantly, the study revealed a need for additional education and training as well as a need for improved tools for documenting, such as templates and computer prompts. Over time, all of these strategies were implemented. Along with ongoing physician shadowing and audits, the process ensured that the organization was both compliant and receiving every penny it was due. The physician-administration relationship improved as a result of the study and subsequent follow-up measures. Both the physicians and the administrators learned a lot about the details of each others’ business. They developed an appreciation for their respective responsibilities and moved forward to make decisions that impacted both of them through a clinical-administration committee.
