Differing perspectives of the medical record

The medical record is unique because it is written for various reasons and looked at from various perspectives. It is not only a written representation of a face-to-face medical interaction between a patient and a provider, but it is also used for medical references, billing and legal purposes. Because medical records are used in so many different ways, it is vital to understand how each group uses the medical record, communicate challenges and obstacles appropriately across departments and functions, and educate users in constructive ways when opportunities are presented.    

In the past, providers have told me their attention is focused on patient care, quality of care and outcomes. Coding and medical record documentation is understandably less important to busy providers. Providers focus on assessing a patient’s situation, isolating the area of concern, and treating the patient in a systematic way. A provider’s concern in the moment of trauma is not obtaining four relevant HPI elements, 2+ ROS, and 1+ PFSH for a detailed history.

On the other hand, coders often take a more calculated mathematical approach to the medical record. They count elements that build up to a level of service. A coder’s responsibility is to ensure documentation supports an associated code. Since they are not patient facing, they use this approach: “If it is not documented it did not happen.” 

Auditors and coders, however, should consider the workflow of providers in order to better understand the medical record flow and function. Likewise, providers could do well to consider the coders and auditors function is to aid, clarify, and ultimately assist in mitigating risk.  Here are some suggestions on how to bridge the gap between providers and coders when focusing on the topic of medical records:

• Designate a physician who understands the role of coding and can educate other physicians within their group.
• Hold quarterly or monthly meetings with the department head, the physician champion and coding teams to discuss changes, trends or general concerns. 
• Proactively send out annual CPT changes broken down into the relevant specialties. 
• Create a coding hotline (phone and/or email) for providers to get answers to coding questions they may have.  

While their approach and functions are vastly different, coders and providers need to find common ground, build a mutual relationship based on trust and understanding, and advocate for each other. It may take a while to build this symbiotic relationship, but once each side feels that the other has an important role in this process, the organization as a whole will benefit. 

Sheldon Barlow, MHA, CPC, is an outpatient pro fee consultant at 3M Health Information Systems.