As a long-time practicing physician (internist/hospitalist), I have seen my clinical colleagues over the years use
some unusual methods to circumvent the doc-
umentation requirements set forth by payers
and regulators. Although I don’t condone
some of these practices, especially when used
to justify the up-coding of charges, I
do understand the pressures levied
on physicians and other providers to
document appropriately. Further, I
recognize the burden this obligation
can cause for the busy caregiver.
Common work arounds
Most of the dubious practices I have observed
do not seem to emanate from a concerted
effort to defraud the system. Rather, they are
the result of providers trying to deliver patient
care and document their activities within the
limited time available. Consider the common
practice of “cutting and pasting” portions of
the clinical documentation from one visit to
another. As a hospitalist, I frequently have
seen this done with problem lists and physi-
cal exam findings. The danger here is that
unless these items are updated, they neither
reflect the patient’s status, which may result in
quality and patient safety issues, nor do they
reflect the actual services provided during the
visit. Likewise, using templates saves time,
but if that comes at the expense of accurate
documentation, it may not be worth the extra
Another common error I’ve observed is for
providers to try to bypass the database function of an electronic medical record (EMR)
and instead enter all information as free text.
This practice seems more comfortable to them,
because it mirrors how hand documentation
in medical records was done before the development of electronic systems. It also saves
time, especially if the free text is dictated into
the record, an option frequently used by those
who have poor keyboarding skills. The consequence of entering too much free text into
an EMR (a sophisticated database with a lot
of prescribed fields) is that most systems can’t
process free text. Thus, the retrieval of data for
a variety of purposes (e.g., quality reporting,
performance improvement, population health
by Ellis “Mac” Knight, MD, MBA
10 means for compliance
» Avoid poor clinical documentation practices that commonly result from limited time for direct patient care and documentation.
» Mitigate the deleterious effect documentation in the electronic medical record can have on face-to-face patient care delivery.
» Ensure compliant documentation of care is accomplished in the most efficient and effective manner possible.
» Prepare for value-based reimbursements, where both clinical documentation and abstraction of performance data from the medical record will be required for billing purposes.
» Step back to re-tool provider clinical documentation processes and procedures.
Ellis “Mac” Knight ( firstname.lastname@example.org) is Senior Vice President/Chief Medical
Officer, at the Coker Group in Alpharetta, GA.