The importance of physician documentation

In addition to maintaining accurate and complete medical records, physicians should keep documentation of the services they provide to support claims submitted for payment.

Electronic health records (EHRs) have their benefits, but also their problems. A major risk factor, called a “note bloat,” is caused by providers’ ability to copy and paste from parts of a medical record, making it large and unmanageable.

Good documentation practices help ensure your patients receive appropriate care from you and other providers who may rely on your records for medical histories.

Best practices for successful documentation are:

• Detailed patient history should be summarized, not copied into the current documentation.
• Copying laboratory or radiology results, already recorded elsewhere in the medical record, is discouraged.
• Pertinent findings for lab, radiology, and pathology should be summarized.
• Do not copy the chief complaint or history of the present illness from a previous encounter. This information must be newly documented for each visit.
• Notes from another provider should never be cloned as your own.