Clinical Chart Review 101
What Every Provider Should Be Thinking About.
Part 1 of 2 .
By Patricia Ramos, AuD
How many times have you seen a patient in the office for a follow-up visit only to find that the information that you really need to serve the patient is not there? This can happen when you are the only provider in a practice but, especially if there are multiple providers involved in the care of the patient. Let’s be honest, when you work in a multispecialty, medical environment there are many variables that can lead to missing documentation, both diagnostic and rehabilitative components of documentation can be extensive based on the number of subspecialties that are provided within your practice.
Let’s review two scenarios that you might discover in a chart audit.
Patient calls in and needs a tubing change or a possible receiver replacement. In reviewing the chart, you realize that you did not document the tubing size or the receiver strength.
- As a solo practitioner in a medical practice providing audiology care, we often get to know our patients very well and there is a lot of information often obtained from the patient in each visit. This leads us to have the challenge of covering all needed areas with the patient, but also documenting it for further future reference. When I first started seeing patients clinically as a solo provider, and yes, of course I was younger, I could remember the patients by their names, their stories, their needs or patterns, (never changed a wax guard, would put the batteries in the HA’s without removing the paper). It is not uncommon for us rely on our interactions and memories of patients concerns as opposed to assuring that we have a documentation plan that is consistent and also allows for us to document quickly and accurately.
- Because of the lack of documentation of tubing size or receiver strength, the only way to address the patient’s needs is to have them come back into the office before care can be initiated versus being able to assure the patient that we can address their problem in an office visit. A great example of this would be making sure one has proper wax guards or receivers in stock before the patient even arrives to the office.
A patient is seen with a complicated asymmetric hearing loss where a masking dilemma could occur. Upon review of the audiogram presented from previous testing, you are unable to assure that the thresholds depicted are accurate because there are no recorded effective masking levels recorded.
- As an audiologist, we must make sure that we are confident in the test results that they have led to an accurate initial diagnosis. Medical and surgical decisions surrounding a patient many times are solely based on the audiometric results. If previous testing performed does provide all needed information, the only option is to “retest”.
- If you proceed with making recommendations based on results that you did not obtain personally and you cannot with certainty know that the thresholds are valid due to lack of recorded masking levels, you could be sending a patient to surgery on improper results and surgery is not indicated.
As you can see from the simple scenarios given above, with only one piece of information missing in the documentation of each example, proper patient care was delayed because the missing information did not allow us to provide care with confidence, therefore requiring additional time on the patient and the provider.
Whether you are using some form of electronic health records program, handwritten notes, or dictating, the key to documentation is having a plan/outline that will allow you to document quickly but thoroughly without missing vital information. One way to do that is to have appointment specific chart note templates that outline the components of each visit type so that as a provider you have all required components of the visit identified, i.e., diagnostics: case history questions listed and only need to input the answers given by the patient; Hearing Aid Fitting Note Template where all information needed for the devices and the fitting i.e. conformity examination performed, reviewed all components and their care/maintenance are also outlined.
Once you have established the components of the chart review process, the next most important step is to determine what to do with the information obtained.
- Determine and prioritize the potential areas of improvement
- Create a clinical documentation plan that is specific to the provider that you are reviewing
- Commit to ongoing clinical chart review to document improvement, self- review and peer review
Documentation is key to patient care and being able to defend yourself in a chart audit, either from an insurance company or a medical malpractice claim.
Let’s start with the basics:
- Is there a medical order in the chart for diagnostic testing performed? This is required in audiology for billing purposes, and you can only bill what is “ordered”.
- Is the patient’s name, medical record number (MRN) and date of service (DOS) included on every page of documentation for the patient?
- Is there documented medical necessity in the chart, i.e., reason for appointment? must always be medically based to be able to retain the monies paid upon audit.
- Do the services that were rendered match the patient complaint and documented history?
- Does the audiogram and other testing results have the information as required by your state? Calibration date, Name of equipment and credentials of who is performing the testing to name a few.
- Do you have appropriate time stamped or written signatures of the provider that is billing for the services?
- Are physical exam findings documented, complete, accurate and appropriate for the patient reported symptoms and test ordered?
- Is all documentation accurate and legible?
- Is there clear documentation of the assessment, clinical impression or diagnosis for all testing performed, and plan of care for the patient?
Need a place to start? Look for the Chart Audit Form in May!
