When I was a director of patient accounting, one of the gripes I sometimes had with my billing personnel was their lack of accuracy when it came to leaving notes. It was the only problem I had with them, and it didn’t seem to matter what I had to say, I couldn’t get the majority of them to leave accurate notes.


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The problems with this were multiple. Sometimes when they followed up on their own work they couldn’t understand what they’d been trying to say. If someone else had to follow up on their work, those folks also didn’t understand.

Sometimes they didn’t write notes immediately after taking an action, which means here and there that they put notes on the incorrect account. They also didn’t have good judgment when it came to deciding which accounts needed more detailed notes, such as when talking to a patient, and which only needed a small entry. If notes don’t make any sense and aren’t detailed enough, they’re useless.

I had the same problem when I was acting as the compliance officer. We would audit most hospital departments, including medical records, and I was amazed at how often the records from a department did not match the medical records. There were certain procedures that would be coded by medical records that a department would object to, but when the notes were looked at it matched what medical records coded instead of what the department said it was.

This was important because if an insurance company challenged paying for a claim and the medical record didn’t fit with what was coded, they were going to deny the bill or pay less than they should have. This also happened when physicians billed claims and coded what they did differently than what the hospital coded. Talk about nightmares!

Accuracy in health care is integral to performance. I saw it years ago, and I still see it happening now.

Years ago I was consulting at a hospital a couple of years after the new infusion charges came in. The first thing I noticed was the billing software company seemed to have missed the update on how to bill for those charges, which was problematic enough. Later on, during the period I was addressing the issue, I was talking to a group of nurses about the updated charges. I asked them how they could verify that they had been giving the infusion treatments a doctor had requested when they didn’t put down the time. Not only did they not put down the start time, but one of the nurses said that they had never put down any information when they gave patients medication other than the pharmaceutical requested.

I was stunned by that admission at the time, and worked with administration to get it rectified, thinking it was just a lapse of judgment at this particular hospital. A couple of years later when my grandmother was in the hospital in a different city, I took a look at her chart at the end of the bed and noticed that there was no listing for most of the medications they supposedly were giving her.

When I requested that the physician come to the floor to talk to me about it, he looked at the records and said that the medication they’d written down wasn’t the medication that he’d prescribed for my grandmother. When she was eventually transferred to a nursing home, they found she had a hole in her back that no one at the hospital had noticed, let alone put in her medical record. Anyone who doesn’t think that’s problematic needs to lose their job.

As a consultant, I believe if my work was that shoddy I wouldn’t have a career. Sometimes it might seem excessive to the client, but I like making sure no one can accuse me of mismanagement later on down the line. Isn’t it always better having more accurate information than not having enough at all?

It’s imperative that hospitals and all other health care entities formalize their policies when it comes to capturing information and writing down notes. They need to strive for better accuracy across the board, because they love telling everybody how proficient they are. If they don’t log everything that’s going on, no one’s going to believe them. It doesn’t matter which department it is; everyone needs to be more accurate in capturing what’s going on.

It’s just like Judge Judy once said: “If it isn’t written it didn’t happen.”
 

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