Three common documentation mistakes you can help fix

May 3, 2016

by Glenn Krauss, Regional Director of Enterprise Solutions, ZirMed

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify some common documentation errors and then how to correct them.

Documentation can be a headache for everyone, from the physicians who have to take precious time away from patients to document in the EHR to the case managers who have to track the physicians down to fill in gaps when information is missing from the medical record.

The case manager plays a crucial role in helping to make sure medical record documentation not only supports billing and coding to ensure accurate reim­bursement, but also clearly communicates the patient’s condition to the entire clinical team.

It needs to be complete, accurate, succinct, and effec­tive, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at ZirMed. However, it’s often anything but. Krauss says he often comes across documentation that case managers could help clarify, and he recently offered some real-life examples (with details changed to protect patient privacy) to illustrate key points.

Below are some examples of documentation as it was written and a discussion below each example describing how it may be improved.

Patient A

The common problem this chart illustrates: Insufficient clinical information.

Chief complaint: Pain in right lower back, hip, thigh.

History of present illness: The patient woke up with pain in the right hip-no trauma-and was able to walk on it. She required morphine and Toradol in the ER. An X-ray showed possible impacted pathological hip fracture. Dr. A was consulted and he saw her on the floor and called me 30 minutes before I saw her. His conclusion was that she has OA in her back but no fracture. He felt she could go home, and therefore I visited the patient and  prepared this documentation.

The patient denies any other symptoms; however, when she rolled over in bed she reported severe pain in her right anterior hip and down her leg. The patient took some aspirin and Aleve. No chest pain, no new dyspnea, no back pain, and no change in urine or BM are reported.

Impressions and plan:

  • Diagnosis: Right groin pain
  • Course: Progressing as expected
  • Orders:Add Vicodin and discharge patient, follow up with Dr. X this week
  • Education and follow-up: Counseled patient, family
  • Discharge planning: Plan to discharge (to home) muscle tear, venous thromboembolism prevention, Dr. X in one week

The analysis: This patient was initially admitted as an in patient and then went home  23 hours later. The problem results in a lack of information written in the chart. According to the information recorded, she didn’t qualify for an inpatient stay and the UR review missed  the problem, says Krauss. There is not enough information in this case to describe and show the medical necessity of an inpatient admission. Based on the information in this chart, the patient should have been discharged home from the emergency room.

The major issue with the history of present illness doc­umented in this example is that it doesn’t demonstrate the specific acuity and severity of the patient’s condition. An effective HPI accurately and completely character­izes and chronologically describes the patient’s signs and symptoms from the time they manifest themselves until the patient comes to the emergency department or other venue for care.

There were only vague complaints outlined in the record and it doesn’t clearly show the severity of pain on a pain scale, says Krauss. There is also no compari­son of the pain on a pain scale before and after t he patient was medicated  with pain medication in the ER, so there is no way to make any sort of comparison or to chart the patient ‘s progress. It doesn’t sufficiently answer the question: What was it about the patient’s pain status, other complaints or physician clinical con­cerns, that drove the physician to admit the patient to the hospital with a reason able expectation of at least two midnights?

To demonstrate acuity, it’s imperative to include spe­cific details of the case with a strong focus on eight ele­ments, says Krauss. For example: Mrs. Jones, a 75-year­ old female, presented to the emergency department at 3 a.m. with extreme hip pain that began about five hours prior to presentation; the pain was initially a 10 on a scale of one to 10. The pain was described as shooting pain to her legs and groin that woke her up out of a dead sleep at home at 1 a.m.

She denied any history of falls and has no history of malignancy. Patient took some Aleve, but still had severe pain, thus the presentation to the emergency room. Pain is worse when she stands; she has trouble taking more than three or four steps without excruci­ating pain radiating down to both legs, causing her to stop. Patient states she is other wise healthy and regu­larly runs four miles a day at least five days per week.

“We can’t tell from the original chart how extreme her pain was in the ER, what her response was to pain medications in the ER, which would pain t a clinical picture of patient acuity. In short, [we don’t know]  what was clinically known by the physician and clinically relevant at the time the physician exercised clinical judgment and medical decision-making to admit the patient as an inpatient with a reasonable expectation of a two-midnight stay,” says Krauss.

The chart also fails to include other factors that led up to this pain episode, such as if she was on any medication known to contribute to an osteoporotic fracture such as steroids or Depo-Provera.

The fix: The case manager or UR specialist should have flagged this case because it doesn’t meet medical necessity and gone back to the physician and requested any additional information or thoughts that may more effectively portray the patient’s true clinical acuity and complexity. This would make up for the lack of infor­mation about the patient’s acuity. If the physician was not able to provide any additional details that demon­strated the patient met in patient status requirements, the patient’s status should have been changed using condi­tion code 44, says Krauss.

Patient B

The common problem this chart illustrates: Missing basic information.

Chief compliant: Hypoglycemia.

History of present illness: Patient comes from local nurs­ing home where he was noted to be combative and have an altered mental status. Emergency services found patient to have a blood sugar in the 30s. He apparently continues to receive insulin despite poor appetite. He is currently in the hospice wing of the nursing home. Patient was in the emer­gency department last night with hypoglycemia, but the power of attorney could not be contacted and the patient was discharged. Patient is unable to give any history.

Impression and plan: AMS likely due to either UTI or hypoglycemia, recheck blood sugar now. HCPOA is out of the country. Will keep  to observe.

  • Hypoglycemia: BS 30’s at NH, stop all insulin  and oral hypoglycemic, will run DS Y2 NS +40 meq KCL
  • Hypokalemia: K+ protocol
  • Patient admitted to inpatient status for in patient ser­vices. I expect the patient ‘s stay to be equal to or greater than two midnights in order to receive  those services.
  • UTI: Rocephin IV, Ucx pending
  • A Fib: stable
  • HTN: stable
  • DM 2: Hypoglycemia, stop all insulin
  • Hyperlipidemia: stable
  • CHF: compensated
  • Moderate pulmonary hyper tension

The analysis: In this case, the history of present ill­ness prompts  more questions than it answers. Why was the patient sent home from the emergency department when he was potentially unstable? Why is the patient in hospice care? What was the status of the patient before he left the hospital the night before? The lack of basic and necessary information in this chart is a concern.

TI1e physician in this case listed the chief complaint as hypoglycemia , but really it appears to be a case of poten­tially uncontrolled diabetes related to improper clinical management on the part of the nursing home staff, says Krauss. We can’t tell from the information provided, however, if the patient has an end stage condition such as inoperable gastrointestinal cancer that contributes to inadequate control of diabetes.1l1is is essential to include in the record. Also missing is the reason this patient is in hospice care. What concerns, from a clinical management standpoint, may impact the management of the patient  under this admission? These issues could affect the discharge decision and potential length of stay as well as the need for present hospitalization.

In this case it’s unlikely that the insurance company would pay for this hospital stay because the patient left the emergency department the night before with a similar presentation, according to the history of present illness. It also raises the question: Was that discharge appropriate?

Another question that should be answered in this account is why the patient is not eating, which may have contributed to the blood sugar of 30. Is the unspecified hospice condition contributing to the lack of appetite? Is it ineffective management at the nursing home? These are critical questions that need to be addressed in the chart, says Krauss. A sound discharge plan begins from day one of the admission.

Another problematic aspect of this chart is that it mentions that the patient’s altered mental status may be due to a UTI. But there are no clinical indicators in the chart (including parts of the chart that were not included in this article) to shed light on why this condi­tion was suspected. What clinical criteria did the physi­cian use in making the diagnosis of UTI? Is the patient subject to repeat catheterization in the nursing home? Is the patient unable to use the bathroom or have urinary retention? And there is no indication of testing or results of the UTI investigation  in the chart.

Frail elderly nursing home patients may have chronic bacteria in the urine that may or may not represent a true UTI. It’s unclear whether the patient will need a two-midnight stay without knowing if the patient has a true infection.

The fix: In this case, the case manager or UR special­ist should  have gone back to the physician for addi­tional information. Although the physician says that the patient needs two midnights of care, the chart doesn’t support that contention and the patient doesn’t neces­sarily meet criteria for an inpatient admission.

“You can’t just have a statement of two midnights; you also need to document the severity of illness and the plan of care,” says Krauss.

What is the risk to the patient if he doesn’t receive hospital-level care? An easy way to remember what Case Management Monthly should be in the chart is to focus on a checklist. “I like to call it the 8Ws,” says Krauss.

  • Where has the patient been?
  • Where is the patient now?
  • What are you thinking?
  • Why are you thinking that?
  • Where are you going and why?
  • What did you find when you got there?
  • What actions did you take?
  • What actions are still needed and bow long is it going to take?
  • What actions remain for post acute care?

Ultimately what the chart needs to do is to paint a true picture of the patient’s condition so someone who doesn’t know the patient or the situation can get a clear understand­ing of what’s going on. It also needs to describe and show why the physician believes the course of action is correct.

Article posted with permission of ACDIS, © 2016. Visit for more information or to become a member.

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