The case for accurate and complete physician documentation.

Abstract

While many physicians consider clinical documentation requirements an onerous intrusion into their clinical practice and resent the usurpation of the medical record by billing personnel, the reality is that the pressure for clinicians to perform better in this regard is unlikely to change anytime in the near future. Hopefully, for the reasons outlined in this paper, health care practitioners will learn to rationalize changes in their documentation habits. Quality, profiling and medical-legal outcomes are at stake. Physicians who take pride in their performance must learn how careful attention to accurate and complete clinical documentation will enhance the recognition of their efforts by third party payers, healthcare rating services and the legal system.