Effective Auditing of Physicians' Notes

Healthcare Training Resource
July 30, 2012 — 1,264 views  
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Proper auditing of physicians' notes is essential in a hospital or clinical setting as it ensures proper medical diagnoses are submitted to health insurance companies and keeps an accurate record of treatment. Physician documentation is important during office visits, consultations, treatment and care and any time healthcare staff encounters a patient. According to Life & Health Library, when this information is under-documented it can result in loss of revenue, malpractice liability, exposure of patient care information to unauthorized parties and payer audit risks due to an incomplete medical record.

The source states the biggest problems in terms of under-documentation are associated with physicians under-coding services in hopes of decreasing out-of-pocket costs and in fear of Medicare audits. Additionally, some physicians are simply not recording everything that occurs during a patient visit. Whether this stems from a physician finding this to be a hassle or if it's because of an honest oversight, complete and accurate physician documentation must be a priority.

Auditing physician notes is when documentation on medical records is compared to the service reported for billing. An audit typically consists of reviewing about two weeks of patient encounters and what was recorded during this period. This can be adjusted depending on how many patients a physician sees, and how often an audit is completed is subject to the facility and other circumstances. However, the resource suggests all audits should focus on what is documented in the medical record and whether the services reported for billing reflect each other.

An audit should also determine if key details in patient histories and services are recorded. Other information an audit may reveal is if the notes are legible. Legibility is essential because if notes can't be read, it's the same thing as not taking notes at all. Also, an auditor should be on the lookout for details such as if negative or normal test results were recorded and if any coding shortcuts caused errors.

It may be necessary to shadow a physician during a patient encounter to have an effective auditing process. After all, an auditor will be unable to determine if something was completed or said during a patient visit that the physician failed to record, unless someone else is there to witness the occurrence. Finally, physicians should be prompted to update patient charts as soon as possible. While it may be more convenient to update charts at the end of the day or the next morning, this increases the risk of under-documentation and other errors.

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