Common documentation mistakes case managers can help fix

Documentation can be a headache for everyone, from the physicians who have to take precious time away from patients to document in the EHR to the case managers who have to track the physicians down to fill in gaps when information is missing from the medical record.

The case manager plays a crucial role in helping to make sure medical record documentation not only supports billing and coding to ensure accurate reimbursement, but also clearly communicates the patient's condition to the entire clinical team.

It needs to be complete, accurate, succinct, and effective, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at Zirmed. However, it's often anything but. Krauss says he often comes across documentation that case managers could help clarify, and he recently offered some real-life examples (with details changed to protect patient privacy) to illustrate key points.

Case managers can help resolve common problems found in patient charts, including insufficient clinical information and missing basic information.

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