Time keeps on slippin', slippin', slippin... (and so does my documentation!)

By | Oct 22 2013       0 Comments      Print

OK, I don't want to know if you haven't heard the song this article gets its title from. The 70's weren't that long ago, were they?

Seriously, time does have a way of slipping by. While it's been a few years since I was a clinician, I still recall how hard it is to take care of people and also write down what you did. It's even harder to write it down well. And even harder to do it in time.

Did you know that we have standards for the timeliness of documentation? You very well may. But do you know why we have them? There are several very good reasons. First, documentation written soon after the encounter is likely to be more accurate and complete. UM frequently encounters cases where they deny additional services for a consumer based on what they read in the record. When the case manager calls to discuss the case, he or she gives much more information which then allows UM to document medical necessity for additional services. This is not an uncommon occurrence. But, managed care issues aside, I am concerned because anyone reading a record in this situation would not know what really happened with the consumer.

So, reason 1: sooner documentation is better documentation.

The second reason, I’ll call the teenage bedroom phenomenon. If we make our son clean his room one Saturday morning (assuming, for the sake of argument, that we could actually accomplish that!), the very same afternoon there will be one pair of pants on the floor. If he were to pick them up, it would only take a moment. But we all know how this story goes: Saturday night, there’s a shirt too. Sunday, some socks and underwear. Monday, old homework and candy wrappers. Tuesday, soccer practice remnants. Pretty soon, cleaning up has become a daunting task.

I hope the metaphor is clear: if you let your documentation pile up, you will quickly be overwhelmed, and things will slip further and further behind.

And, speaking of underwear, why did Mom always tell you to wear a clean pair?  “You never know, you might get hit by a bus!”  While I doubt the ER staff will care about the state of your skivvies after your encounter with the MTA, your colleagues and consumers will appreciate it if it’s clear where things stand with your cases.  Stuff happens, and we owe it to our consumers to minimize the interference with their services.

Another reason: you never know what will happen or who will be looking at the record. What if your consumer was involved (even as a victim) in a crime, and the record was subpoenaed?  What if a crisis occurred and you weren’t available to discuss the case?  I’ve been on both ends of that situation – needing to know what was going on with someone else’s case, and having failed to include enough information for someone else who needed it.  I felt I was failing the consumer in both cases.

Finally, it’s required.  While there is not a specific page of the Medicaid provider manual that says “do it within X days,” the expectation is that, on any given day, Medicare or other auditors could swoop in and find the records current through yesterday.

Our standards are as follows:

  • within 24 hours for crisis services (immediately is best)
  • within three days for all other services (immediately is still best).

How are we doing?  When we started measuring timeliness in 2012, about two-thirds (68%) of documents were timely.  Now, we're over three-quarters (77%).  Most providers have improved, some dramatically.  But there are a few who still struggle.

Reports are available on the Intranet (GHS staff) and the OPSC (contractors) that can summarize documentation timeliness for a provider, a program, or even an individual staffperson.  How are you doing?  Maybe it's worth a few minutes of your time to find out.

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