American College of Physicians: Internal Medicine — Doctors for Adults ®

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An efficient form-ula for documentation

From the January ACP Internist, copyright © 2008 by the American College of Physicians.

“If it’s not documented, you didn’t do it.” Good documentation is critical, and in today’s environment it must be performed quickly, accurately and efficiently. Using good forms and templates can save time, reduce medical errors, assure completeness and minimize coding guesswork. Accurate coding and documentation is easier said than done—it’s an art, not a science.

Can forms make much difference in a practice? A cadre of well-formatted forms designed to work together can help an office run more efficiently and a properly documented case can reduce your legal risk.

  • If your registration form does not include everything that you need in a logical order, submitting a clean claim for all future reimbursements is more challenging. If the registration form does not include all the contact information you need, then when a test result comes back that requires immediate attention, you could encounter both quality and efficiency issues.
  • Good history and physical documentation ensures both thorough record keeping for clinical follow-up (and medico-legal concerns) and appropriate coding.
  • Problem lists, logs, progress notes, and flow sheets, if well-designed and implemented, can keep your chart well-organized and provide an at-a-glance review of critical values to help clinicians provide high quality care.
  • Medication lists (prescription and non-prescription) that are neat, complete, and kept up-to-date can facilitate accurate refill requests and help make office visits more efficient.
  • A well-designed family and social history form can save time for staff and clinicians, as well as ensure that key questions are not missed. Medical staff and providers are human and cannot possibly remember everything every time.
  • If you dictate, using dictation prompts can aid in determining and supporting the appropriate level of service.
  • Properly conducted self audits are a good way to ensure internal quality monitoring of clinical care. Good coding and documentation auditor worksheets can help the practice conduct a self audit.
  • Well designed and displayed signs can ensure safety and serve as reminders, especially regarding common problem areas such as refrigerators, labs and waiting rooms.
  • Patient education materials can supplement information given orally to patients and provide them with a reminder of important facts often quickly forgotten.

Physicians want tools that can help minimize the guesswork of coding and documentation. ACP offers physicians a matrix of forms that includes flow sheets, progress notes, problems lists, patient history questionnaires and others that are clinical in nature. There are also numerous office forms for patient registration, encounters, telephone messages and other practice management issues. Because no single form can meet the needs of all practices, many of the forms are intended as examples or models to be used as a development tool. The forms can be downloaded here and here.

PMC Tips is a regular feature on practice management from ACP’s Practice Management Center.

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