Documentation and Data Improvement Fundamentals

Ruthann Russo, JD, MPH, RHIT


The absence of complete documentation in patient medical records can have a negative effect on statistical databases, financial planning, clinical preparedness, and gross revenue for the healthcare organization. It is for this reason that every healthcare organization should be focused on ensuring accuracy and completeness in clinical documentation, at any cost. Documentation improvement is not a new concept in healthcare, but rather an evolving trend.

The healthcare system in the US is constantly changing. First, from a clinical perspective, we have seen a movement away from postponing care until patients are severely ill and in need of hospitalization to preventive medical care. Along with this trend, we have seen fewer, but more severe inpatient admissions and an increase in outpatient admissions over the past decade. Second, from an information management viewpoint, there has been an increasing trend toward computerization of medical records. The government has responded to this trend by implementing privacy and security protections through HIPAA legislation. Third, reimbursement to healthcare providers for services has evolved. Many of the initial changes were triggered by HIPAA legislation as well. These began with the Medicare fraud and abuse initiatives of the 1990s and have continued through the present with CMS policy updates focusing on physician documentation.

The two most important aspects of patient medical record documentation are as follows:

  • The attending physician's documentation is key throughout the patient's stay. In each case, the model stresses that in good documentation practices it is important for the attending physician to either interpret the documentation of other clinicians or tests, or confirm the findings of other physicians.
  • Documentation is the key to appropriate billing. In each case, documentation forms the basis for coding and the eventual bill that is submitted for a patient's care.

What Is Clinical Documentation in a Patient's Record?

Clinical documentation in a patient's record includes any and all documentation that relates to the care of the patient during the patient's stay or encounter. In the inpatient setting, some of the important pieces of inpatient documentation include:

Attending Physician Documentation

In the acute care inpatient setting, the attending physician is the central point for all documentation in the patient's record. It is the responsibility of the attending physician to determine the relevance and importance of all other documentation in the patient's record. Some of the more important clinical documentation components from the attending physician during the patient's stay are described below.

History and Physical

The patient's history and physical is one of the first pieces of documentation that appears on the patient's record. This document usually includes not only information pertaining to the patient's history, but more importantly, pertinent information regarding the patient's current condition. Here, the attending physician should document his/her assessment of the patient's current condition. It is possible that the attending may be working with symptoms and differential diagnoses at the time of the history and physical exam. It is important that s/he document these symptoms and any differential diagnoses in the history and physical. Although these conditions may be eliminated once a definitive diagnosis has been established, it is important to understand (and have documented) what the physician was working with in terms of initial or "working" diagnoses. This information can be used to substantiate any tests or consultations that are ordered during the stay.

Example:   If a patient is admitted with syncope, and the physician orders both a neurological as well as a cardiology consultation, it is important to know that the attending physician is working with differential diagnoses of   "possible CVA" and "arhythmia." These diagnoses (one a neurological diagnosis and one a cardiology diagnosis) justify the ordering of a consultation from each clinical area.

Progress Notes

Progress notes from the attending physician chronicle the entire patient stay. Ideally, progress notes should be present on every day of the patient's stay. And, in cases where the patient's condition is changing quickly, progress notes may be warranted more frequently than daily. Progress notes usually contain information regarding the "progress" that the patient is making. Response to testing, treatment, and medications should be recorded. More importantly, on an ongoing basis, the attending physician should provide documentation regarding the patient's diagnoses. Any new diagnoses or any diagnoses that have been definitively established should be documented. The importance of placing clinical documentation in the progress notes--as opposed to waiting until the discharge summary--can not be stressed enough. In addition to chronicling the patient's care, progress notes are also the best place for the attending physician to:

  • State agreement with a consultant's report
  • Determine the significance of ancillary test results (lab, radiology, etc.)
  • Eliminate or add working or differential diagnoses
  • State whether a patient has any conditions that should be defined as "possible," "probable," or "rule out"         


The attending physician must provide an order for all treatment and care that the patient receives. Without this direction from the attending physician, the team attending to the patient would be frozen. From a documentation perspective, it is important for the attending physician to document is the reason why an order is made. This information provides complete detail for the actions of the physician in reference to the patient's condition.

Example: For an order for antibiotics for a patient, rather than simply "cipro 100mg b.i.d.," it would be more complete for the attending physician to document "cipro for UTI 100mg b.i.d."

Procedure Reports (Attending Surgeon)

Surgeons should dictate reports for all procedures performed during the patient's stay. The surgeon initially records findings at surgery in the progress notes. But the more detailed accounting of the procedure is in the dictated operative report. The body of the report should document every possible detail about the procedure.

Discharge Summary

The discharge summary is viewed as the synopsis of all events during the patient's stay. It is important that the discharge summary is just that--a summary of events already chronicled in the patient's record. Events, diagnoses, and assessments should not be recorded for the first time in the patient's discharge summary. At least, clinical evidence of every condition documented in the discharge summary should be found somewhere in the patient's history and physical, progress notes, orders and/or operating room reports.

Other Physician Documentation

In the majority of inpatient cases, other physicians, in addition to the attending physician provide documentation in the patient's record. These may include consultants, anesthesiologists, and pathologists in the case of patients undergoing surgery. This may also include radiologists and cardiologists responsible for interpreting diagnostic test results. Let's address these documents individually.

Consultation Reports

When an attending physician orders a consultation, and the consultant agrees, the consultant is responsible for documenting the results of his/her findings in the patient's record via a consultation report. The report should include the results of any history and physical performed independently by the consultant. In addition, the report should include findings of tests and an assessment from the consultant regarding his/her expert opinion about the patient's condition. The consultant may be providing a second opinion, may be determining the patient's actual diagnosis, or may be assessing test results. Regardless of the consultant's findings, the attending physician has the final say about the patient's condition. AHA Coding Clinic , the official guidance for ICD-9-CM coding, declares that when there is a disagreement between the attending physician and another physician treating a patient on an inpatient basis, the attending physician's opinion always takes precedence. A broad application of this policy would require the attending physician to agree with (or re-document) any findings of the consultant in order for that information to be considered a final and definitive finding regarding the patient's condition.

Anesthesia Reports

In the case of any patient scheduled to undergo surgery, there is a requirement for an anesthesiology evaluation. The evaluation occurs both before and after surgery. Before surgery, it is important for the anesthesiologist to determine any conditions that the patient may have that would require special treatment or management during the surgical episode. Therefore, it is important for the anesthesiologist to clearly document any condition that the patient has that is impacting care. Again, it is advisable for the attending physician to document agreement with the anesthesiologist's findings in order for the anesthesiologist's documentation to be relied upon and abstracted for coding purposes. It should be noted that this policy exists only in the inpatient setting. Currently, in the outpatient setting, it is acceptable to rely upon the anesthesiologist's documentation without further intervention from the attending physician.

Pathology reports

When tissue is removed during a surgical episode, it is sent to pathology for analysis. The pathologist is responsible for dictating a pathology report that details the findings of the pathological analysis. In the presence of attending physician agreement, this information is then relied upon for additional detail regarding the patient's condition during the stay.

Radiology/Nuclear Medicine Reports

If an attending physician orders radiology tests during a patient's stay, those tests are then performed and interpreted by a radiologist. The radiologist is then responsible for dictating his findings and assessment in the form of a radiology report. Generally, the radiologist provides an "impression."   This impression is not considered to be an official assessment or diagnosis for the patient until the attending physician designates his agreement with the diagnosis.

Cardiology Reports

If an attending physician orders an EKG, echocardiogram, or other cardiology test, the test is performed and interpreted by a cardiologist. The cardiologist is then responsible for dictating his findings and assessment for the test. The impression provided by the cardiologist is not considered to be an official assessment or diagnosis for the patient until the attending physician designates his/her agreement with the diagnosis.

Other Clinical Documentation

Other clinical documentation in the patient's record is provided by nursing staff and other ancillary clinical staff who may be treating the patient. The documentation provided by these clinicians is extremely important to the overall picture of the patient's stay. From a reimbursement and coding perspective, the documentation provided by these clinicians is "supplementary" to the attending physician. Often this documentation is rich in detail that is lacking in the attending physician's documentation. However, unless the attending physician also documents the conditions noted by other clinicians in the patient's record, it may not be relied upon for coding and abstracting purposes. And, in the final analysis, documentation in the patient's record only gets carried further as a result of the documentation being coded and abstracted. So, without attending physician acknowledgement and documentation of the detail provided by ancillary clinicians, this information becomes lost in the actual patient record.

Example:   A nursing note documents a patient with post-operative urinary retention. The attending physician orders a foley catheter placed, but does not document the reason for the order. The nursing staff places the catheter and notes that finally, on the second day post op, the patient has begun to urinate. In this case, although there is significant documentation that the patient had post-operative urinary retention, this condition can not be coded unless the attending physician documents the condition in the patient's record.

Why Clinical Documentation in a Patient's Record Is Important

Patient Care and Quality

The clinical documentation in a patient's record forms the basis for current and future care of that patient by the healthcare provider. The documentation in the record will be relied upon by clinicians in the healthcare provider setting to make decisions regarding the patient's care. This includes everything from the more "objective" type of documentation, such as the results of laboratory tests, to the more "subjective" type of documentation, such as a consultant's opinion regarding the patient's condition. In either case, the documentation should be as complete and detailed as possible. Unfortunately, in the case of most attending physicians, there is little time to dedicate to extensive documentation in the patient's record. Most physicians prefer to spend the time they have actually treating the patient and not documenting it. However, it is important to understand that the treatment of the patient includes not only "one-to-one" care but also the documentation of that care. And, there is no time like the present--at the time the physician is actually treating the patient--to document the care being rendered. Concurrent documentation, for example in the progress notes, is one of the best ways to accurately record care and treatment of the patient. Concurrent documentation is reliable, accurate, and most likely to actually reflect what occurred during the patient encounter. As a result, current and future care is more likely to be of a higher quality , since it is based on correct historical information about the patient.

Legal Protection

Detail in documentation can provide strong legal protection to the healthcare organization. In the absence of documentation, a court will construe the evidence against the defendant in an action. Therefore, it is important for the patient's medical record to contain detailed, complete, and accurate documentation in the event that the document is needed as evidence in any legal proceeding.

Operations and Management

The data that is abstracted from a hospital inpatient record in the form of ICD-9-CM diagnostic and procedural codes is used by healthcare administrators to plan for operations and ongoing management. For example, the cardiology product line team may be following and trending the abstracted data for all cardiology diagnoses and cardiac catheterizations on a monthly basis. If diagnostic or procedural information is not clearly documented in the patient's record, it can not be coded and will not appear on the management team's abstract. In this case, it is possible that effective operational management could be impeded without accurate data.  

Strategic and Financial Planning

Prospective payment for inpatient cases relies upon ICD-9-CM diagnostic and procedural coding. ICD-9-CM coding relies upon complete and accurate documentation in the patient's record of the patient's diagnoses and procedures performed during the stay. Inaccurate documentation results in inaccurate coding assignment which results in inaccurate DRG assignment and payment to the hospital. Financial planning and budgeting uses prospective payment (DRG assignment) as the basis for gross revenue receipt for inpatient stays. Inaccurate documentation can have a significant impact on the hospital budgeting and financial planning process.


Coded data in the form of ICD-9-CM codes is used by teaching hospitals, state hospital associations, professional medical associations, government entities, and other organizations for research in many clinical areas. Research activities assume that the data is accurate, and projections are made based upon the data. In the event that documentation is inaccurate (resulting in inaccurate coded data), the effectiveness of research activities is significantly impeded.

Reimbursement/Gross Revenue

One of the most significant effects of incomplete documentation in a patient's medical record is inaccurate reimbursement that results in inaccurate gross revenue to the provider. In the absence of accurate documentation, a provider should assume that revenues are not accurate, as well.

Source: 2004 IFHRO Congress & AHIMA Convention Proceedings, October 2004