AHA Coding Clinic® for ICD-9 - 1984 September - October
Medical Records and the Medical Staff: A Joint Effort in Documentation
by Minnette Terlep, ART, director, Medical Records, St. Joseph Medical Center, Joliet, IL The Medicare prospective pricing system has placed greater importance on complete and accurate documentation in the medical record. In order to achieve such documentation, open communication must take place between physicians and the medical records staff. The first step is physician education. The medical staff needs to be made aware of the importance of ensuring that diagnoses are substantiated by the diagnostic findings documented in the medical record. The UHDDS definition of principal diagnosis (the condition established after study to be chiefly responsible for occasioning admission...
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Article Overview
This article addresses how hospitals can strengthen documentation through cooperation between physicians, medical records personnel, and medical staff committees. It focuses on physician education, record review practices, communication methods, bylaws and delinquency monitoring, and the development of local coding guidance in the context of prospective payment and hospital coding workflows. The piece is aimed at medical records professionals, coders, physician advisors, and hospital administrators who manage documentation quality and coding support processes.
Why This Topic Matters
Incomplete or unclear documentation can affect diagnosis specificity, case grouping, and record completion workflows. The article explains why coordinated communication and committee involvement matter for maintaining accurate hospital records and supporting coding operations.
Article Sections
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Physician education and documentation expectations
Introduces the importance of educating physicians about documentation quality and diagnosis specificity in the hospital record. Discusses the role of classification awareness in supporting accurate record abstraction.
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Physician participation and committee support
Reviews the kinds of medical record information coders may examine and the communication methods used when clarification is needed. Also covers physician-adviser support, conflict resolution, and related committee involvement.
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Timely completion, coding guidelines, and rapport building
Addresses record completion expectations, local guideline development, and practical ways to build cooperative relationships between physicians and medical records staff. Includes discussion of workflow support, monitoring, and educational exchange.
What You Will Learn
- How physician education supports better hospital documentation
- What kinds of record sources may be reviewed for documentation completeness
- How medical records committees can assist with clarification and support
- Why timely record completion and bylaws enforcement matter
- How local coding guidance and staff rapport can improve documentation workflows
Who Should Read This
- Medical records directors
- Hospital coders
- Health information management staff
- Physicians
- Medical staff committee members
- Hospital administrators
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