More than a few years ago, when I was just starting out as a hospital administrator in a large teaching hospital in Brooklyn, NY, the director of medical records told me the saying I’ve repeated often: “If it isn’t written, it didn’t happen.” A few years ago, I had the delightful experience of an IRS audit. As a small business person, one of the first questions had to do with mileage. The conversation shut down right away when I could hand over a contemporaneous log of all business trips and my daily calender. The examiner only flipped through the log.
The February 17 issue of Medical Economics magazine has a good review article with several resources on documentation. Using standard forms helps to insure that you capture the information you need. It also eliminates the “friction” of recordkeeping – you become accustomed to what information you need and where to record it, so you don’t waste time thinking about where to put something.
Another good source of sample forms is from Don Self, a Texas based consultant, who has collected forms from a variety of other practice billers and managers and posted them on his site. I will warn you – Don has an “interesting” sense of “humor”, so you may want to scroll down to get to the forms. Nothing R rated, just “interesting.”
The upshot: document what you did, giving enough information that another reader could follow what your did and why. And please, please use professional looking forms, not the latest ad-laden handout from some pharmaceutical company.