Documentation for a multidisciplinary pain practice

Documentation in the medical record communicates pertinent facts regarding the patient's history, diagnostic tests performed and their results, objective and subjective data, as well as treatments rendered and the outcomes. Proper documentation allows the physician and other healthcare providers to plan and evaluate the patient’s past, current, and future health problems. Therefore, it is extremely important for the record to be completed in a timely manner and to be legible. Inability to retrieve pertinent information regarding the patient’s care may result in malpractice and/or negligence. Accurate documentation also allows for timely claim reviews and payment. Medical billers and coders must be able to retrieve information from the medical record that demonstrates medical necessity as well as properly code and bill for the services rendered and the supplies utilized during the treatment. Many insurance providers and quality resource managers may review documentation for appropriate utilization review and quality outcome evaluations. These individuals are scrutinizing the documentation to ensure that standards of care were meet which may result in nonpayment if they were not. The medical record may be utilized for research and educational purposes. The documentation of the diagnosis, treatment and the outcomes may be useful in developing future health care trends, standards, and guidelines.