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Top 10 Tips on Clinical Documentation

Discover essential tips for effective clinical documentation from Ted Markgren, CO. Your clinical records reflect your professionalism. Are your notes organized and readable? Do they document communication with referrals and evaluations? Learn the importance of aligning clinical and billing records, justifying services billed, and clearly defining care plans. Ensure safety inspections are documented and establish follow-up protocols. This guide aims to enhance your clinical documentation skills, limit liability exposure, and ultimately present a professional image.

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Top 10 Tips on Clinical Documentation

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  1. Top 10 Tips on Clinical Documentation Ted Markgren, CO

  2. What your chart says…. says a lot about you!

  3. So, how is all that chart stuff coming along? • Are you better? • Are you worse? • No change?

  4. Are you a professional…. • ….or are you a supplier?

  5. Tip number 1 • Are your clinical records organized? • Are the notes in chronological order? • Are there blank spaces between entries?

  6. Tip number 2 • Can you read your chart notes? • Do you know who wrote it? • Is it signed or co-signed by the clinician?

  7. Tip number 3 • Do you document communication with the referral source? • Does the dispensing script match the detailed script? • If not, does your chart support the change?

  8. Tip number 4 • Did you document your evaluation? • A diagnosis-specific clinical evaluation is a Medicare quality standard. • As a supplier you might “fill a prescription”, but as a professional, you will determine that the prescription is appropriate for the client.

  9. Tip number 5 • Do your records include detailed technical descriptions of the items or components provided? • Do your technical records match your clinical and billing records?

  10. Tip number 6 • Do your clinical records support and justify the items you billed? • Is the rationale for each component explained in the clinical record?

  11. …still on tip number 6 • Speaking of clinical notes… • … can another practitioner take over care based on your chart notes? • Is there a clearly defined plan of care? • Have all adjustments or modifications been recorded?

  12. Tip number 7 • Have you established expected goals and outcomes for the items or services provided? • This is a Medicare requirement! • Think pay for performance

  13. Tip number 8 • Did you document a final safety inspection of the item? • Did you record the torque settings? • Do you even have a torque wrench? • Limit your liability and exposure!

  14. Tip number 9 • Carefully document patient and family or caregiver education. • Is there evidence that you explained the precautions for use of the item? • Can you prove it?

  15. Tip number 10 • A follow-up plan must be included in the clinical record. • PRN is not always appropriate follow-up. • Did the follow-up appointment occur, or was the patient lost to follow-up?

  16. Be sure the chart reflects a professional image……YOUR professional image! Thank You

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