The Art of Documenting – Important For Transcriptionists and Medical Records

Original Post by Gary Patterson at PP&A Transcription News

Most people don’t understand the importance of knowing how to properly document activities in their business and personal lives.  It’s a skill that is becoming more critical as companies outsource their customer service departments and the resultant customer service deteriorates.  In a hospital, much of the institutional documentation process is built into the processes that have developed over time.  However, the art of  being able to successfully document becomes more critical for personal protection as policies are developed to protect the facility but leave the individual left to their own devices.
So, let’s take a look at it.  Most people think that documenting is writing down things that happen; sort of a diary of events.  Think again!  Consider this, “In a court of law, how would that written narrative hold up as evidence?”   The answer is not very well.  The written narrative is good for personal recollections of events but not much else.  Good documenting of events is open to all parties, provides all parties with the ability to respond and records an indisputable sequence of events.  Anything not meeting all of these criteria is less than effective.
This is especially important in Medical Records/HIM where there is constant interaction with individuals (Doctors and administration) perceived by the organization as having jobs more important.  The organization grants them more leeway in their actives, because of their positions as revenue generators.  Most are really good and go about their day working within the system to the betterment of us all.   Some go beyond the leeway granted by the organization and follow their own sets of rules.  Their sets of rules often countermand established policies and procedures.  What do you do then?  This is where documentation becomes critical.
For example, when talking to Medical Records directors, I often hear that doctors not reading and signing their reports is the biggest single headache in their department.  No matter what they do, there are a select few who don’t respond and are always negligent.  One Director had a personal diary of every time that he placed calls to doctors and the messages he left.  Another put the unsigned folders in a special pile with their names on it.  Some hospitals have threatened suspensions and the loss of privileges.  It’s always the same individuals and their behavior doesn’t change.  Most have a variety of excuses usually involving some degree of misconception or miscommunication from the medical records staff.
I don’t have an answer to how to get them to change their behaviors.  If that is what you were looking for, I’m sorry to disappoint.  I do offer a solution on how to deflect blame and not bear the brunt of their bad behavior.  Follow the procedure listed below and you’ll protect yourself by the bad behavior of others.

  • Start by creating a file with their name on it.  This is the file into which all documentation will be stored.  Copies of all correspondences must be put into this file; originals where possible.  Keep it in chronological order.
  • Insure that the date is on all correspondences.
  • In your correspondences, always ask for a response.  This could be in the form of their opinion, their rebuttal, even their acknowledgement that they received the message.  Whether they respond or not is immaterial.  A non-response is deemed to be agreement on their part.  I always prefer something like the following phrase, “If you don’t agree, please let me know what you think.”  This puts the onus back on them to reply.
  • Send all doctors on staff the organizational policies and procedures towards records and completion of their files.  Insure that the date is clearly stamped on the document.  Put a copy into the file.  That becomes the starting point for your documentation.
  • As soon as reports become overdue, send a form letter to the doctor notifying that the following reports are overdue.  Date a copy and file it.
  • Within a week, send another letter stating that the reports are overdue and that according to the policies and procedures of the facility they are to be completed within a specified time frame.  Inform the doctor that noncompliance by a specific date will result in notification to the Chief Financial Officer (CFO).  The fact is that Doctor’s not signing reports directly impacts the ability of the facility to make money.  That is the purview of the CFO and the Chief Operation Officer (COO).
  • On the date specified, send a letter to the doctor in question listing each report that is overdue.  Request a meeting with the doctor in question.  Be very specific on the date and time.  Give a deadline where necessary.  Where possible, hand carry the letter to the doctor to insure reception.  Copy the CFO and the COO.
  • If the date passes, inform the CFO and the COO of non-compliance.  Also, include pertinent sections of the doctor’s contract and the policies and procedures.  Request their assistance by a specific date.
  • Regularly, publish a report to the CEO, with cc’s to the CFO and COO, of all reports in arrears.
    Publish a quarterly report to the CEO detailing the time it takes for doctors to sign and complete reports.  No one wants the exposure that comes from being the person dragging down the performance of the report.

The bottom line is that no one wants the exposure that comes with this system and you have the documentation to show that everyone was kept informed at every juncture.  The finite ‘respond to’ dates insures that the process isn’t infinite.  Remember the old law of human behavior, “People will take as long as you give them.”  You have limited exposure since you can show that everything was done to correspond with the offender and you’ve done everything in your power to protect the fiduciary interests of the organization.  If necessary, your file is your protection showing that everything was done above board.
You can use this process all through your life.  I’ve found it to be especially helpful when dealing with corporations and government agencies.  In the medical arena, refining the process of documenting will provide you with personal protection in every situation.