7 Criteria to Follow for Clinical Documentation Improvement (Part 3): Completeness & Consistency
Posted: Sep 01 2015
In the first segment on clinical documentation, we discussed reasons why high quality clinical documentation is increasingly important. Specifically, we covered the first of seven criteria: Legibility. In the second segment, we discussed criteria two and three: Reliability and Precision. This article is the third in a series of four that will focus on criteria four and five: Completeness and Consistency.
Criteria #4: Completeness
Completeness means that the provider has fully indicated a response to all concerns in the patient's record, including an appropriate authentication. Documentation should include any concerns in the presenting problem(s) and discussion of any condition that may have been present on admission, or which may have developed during the course of treatment.
If diagnostic workup is done, has a sufficient medical reason been documented to support the rationale of the tests? If any diagnostic study resulted in abnormal findings, has any relevant clinical significance been discussed?
Criteria #5: Consistency
Consistency in documentation means that there are not contradicting statements from one progress note to another note. In general, when there are contradictions between different physician's notes, and the attending physician is not available for clarification, the attending physician's documentation will take precedence.
However, if there are contradictory statements within the attending physician's own notes, he or she must clarify by adding an addendum to the discharge summary or completing a final progress note.
Ms. Dorothy Steed, CCS, CDIP, CPC-H, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CPAR, has 38 years of experience in both hospital and physician billing, coding, reimbursement and claims management, specializing in Medicare requirements. Ms. Steed is credentialed in medical coding, compliance, utilization management, utilization review, medical auditing, clinical documentation improvement and patient accounts.