What advice can you give to residents who are starting out their career relative to the importance of documenting his or her work?
Timely chart documentation is required by the provider to record facts, findings, and observations. It also provides communication and continuity of care among health care professionals. If you do not document correctly, this could result in downcoding, loss of revenue for you and the hospital and increase risk for all. Get in the habit of making your documentation compliant and complete, so it reflects the services in a consistent and defendable way. Knowing the CMS 1995 Coding and Teaching physician guidelines, will enable you to comprehend documentation requirements from a coder and provider perspective.
Tracy Goglio, CPC, CEDC
ED Coding Manager