BC Advantage - 2015 Issue 7
Documenting the Patient Record
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Article Overview
This article discusses the role of patient record documentation in supporting continuity of care, accurate reporting, and reimbursement in the context of ICD-10 adoption. It is aimed at clinicians, coders, practice managers, and billing staff who want a general understanding of why documentation expectations are changing and what operational areas may be affected. The article covers the need for more detailed and consistent records, common documentation-related problem areas, and the broader business-process impact of moving to the newer code set.
Why This Topic Matters
Better documentation supports more accurate coding, fewer claim delays, improved data quality, and stronger clinical and financial decision-making. The article is relevant to organizations preparing for documentation changes associated with ICD-10.
What You Will Learn
- Why complete documentation is important for patient care and reimbursement
- How ICD-10 is framed as changing documentation expectations
- Which documentation gaps commonly contribute to billing problems
- Why workflow and time management may need to be reviewed during a code set transition
- How documentation quality connects to reporting and operational performance
Who Should Read This
- Physicians and other providers
- Medical coders
- Billing and reimbursement staff
- Practice managers
- Compliance and operations professionals
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