Optimizing The Revenue Cycle 5 of 12: Documentation

Posted by Crystal L. Miner, MBA-HSA, FACMPE on Jan 9, 2019 7:52:00 AM
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We all know the phrase “If it’s not documented, it didn’t happen.” The question is, “how do you document what happened, accurately, in a confusing EHR, in a way that will meet requirements and allow you to get paid?” Not an easy thing to answer but there are a number of tools and resources for providers and administrators to help. Tools range from the EHR to the billing team (internal/external), and utilizing external resources. Administrators must help their providers be knowledgeable of the tools available and the guidelines required.


Accurate documentation is a key to appropriate coding and charge entry which are major parts of the revenue cycle. Administrators should assure that their providers know how to accurately document what happens in their encounters with patients. Today this revolves around a provider’s use of the EHR, as 85% of office-based providers use one. Providers should not be focused on insurance/payer requirements. This is the prerogative of the billing department. Instead, knowing and following coding and documentation guidelines should be the priority. This requires constant training and communication between a clinic’s billing team (internal or external) and providers. Optimize the Revenue Cycle Documentation.png


When utilizing an EHR to its fullest extent, providers should have templates customized to them. If possible, the forms that providers use to document their encounters with patients should flow in a way that makes sense to the provider. The EHR should flex to meet the provider’s natural workflow. This will allow for the most efficient documentation and lower the frustrations of the provider.  Another aspect of the EHR that should be customized and utilized by providers are any “favorites” that can be created. From pre-filled checklists to medications and orders, to lists of procedure and diagnosis codes, these “favorites” usually shorten long scrolled lists or multiple clicking for documenting.


To customize these templates and favorites, administrators should look to have EHR vendors supply training to providers, create “superusers” within their own clinics, or hiring specific IT contractors or employees that have specific EHR knowledge. A clinic must have constant resources for providers to assist them in utilizing their EHR. However, providers must also know the risks of using an EHR. There are things that make documentation easy in an EHR that can also get a provider into trouble when audited if not used responsibly:

  • Citing forward histories, review of systems, medications
  • Pre-filled documentation templates/forms
  • Quick-text


When using these tools, each encounter must be reviewed before a document is signed. Errors can be easily passed forward through citing older documentation and using pre-filled/pre-created documentation. Best practice is that documentation is reviewed quarterly by internal audit and annually by an external auditor. These internal audits can catch errors often created by using these helpful EHR tools. Follow-up with providers to prevent continuing errors is required. The audit should review the following:

  • Does each encounter explain what is going on with the patient?
  • Each encounter for the patient is unique, clear and concise
  • There is no inaccurate, incomplete, or conflicting information


Other ways to help providers with documentation include dictation tools (dragon) and scribes. A scribe is a modern-day version of a transcriptionist. Usually, they are an unlicensed individual hired to document in the EHR at the direction of a provider. Some practices are training medical assistants to take on this role so that providers may delegate other tasks to them outside of the exam room. A recent MGMA survey found that 35% of respondents use scribes in their practices. There are currently two major suppliers of scribes, Scribe America and Elite Medical Scribes. Though, of those stating that they utilized scribes, only 10.22% stated that they used external services. Most (25.13%) employ their own scribes.


Whether a clinic trains a medical assistant to be a scribe or hires specifically to fill this role, the benefits may be hard to quantify. Many emergency departments are utilizing scribes so that incoming physicians can quickly move from patient to patient. Another reason is so that locums do not have to spend as much time learning the EHR. However, very few studies have been completed to show the amount of time saved utilizing a scribe. There are many variables (provider’s computer skills, EHR usability, etc.) that are often hard to measure or categorize. Some providers use scribes for the opportunity cost – what some call “work/life balance.” Thus, instead of staying hours after clinic to assure their notes are as complete, they use a scribe to be able to go home soon after clinic is complete. Clinics should look at what each provider needs and would work best for them.


Training is a constant for all positions in a clinic, including providers. Administrators are responsible for helping facilitate these learning experiences. Providers are responsible for absorbing the information and applying it to their daily activities. Providers and administrators should work together to define goals regarding documentation and determining which methods will work best for them to meet these goals. If providers can accurately and efficiently document each encounter with a patient, then the next few steps of the revenue cycle will be easier to optimize.


This is Part 5 of a 12 part blogging series on How to Optimize The Revenue Cycle For Your Practice. Be sure to subscribe for email alerts to never miss an article. If you missed anything, check it out here: 12 Part Series 

Topics: revenue cycle management, Medical Practice Improvement, check-in