Proper documentation is critical for increasing revenue. There is a growing loss of income for hospitalsand facilities due to inadequate documentation by physicians. Documentation should provide enoughsupport information to use specific diagnosis codes and bill services to its entirety. There are differentapproaches to improve documentation. Education for the physicians, support systems, and the use ofelectronic health record systems, are ways to assist in the improvement of documenting in a patient’schart. There can be other consequences to improper documenting such as audits, fines and mistakesthat can be harmful to the patient. I used and article by Richter E; The Advisory Board Company,Washington, DC, USA. [email protected] Shelton A, Yu Y, Source: Healthcare FinancialManagement: Journal of The Healthcare Financial Management Association HealthcareFinancial Management 2007 Jun; Vol. 61 (6), pp. 44-7. to obtain information.If vital healthcare information goes undocumented, it results in unspecified diagnosis andunbilled charges. This leads to underpayment of services to the physician and facility. If aservice is provided by a physician, and the medical notes are not accurate and complete , serviceswould not be billed to the highest level of service. This type of documenting over time can causea substantial loss of revenue. Physicians who continue to under document a patient’s care andthe services performed shows inaccurate level of patient severity. Improving documentation canincrease hospital’s clinical and compliance efforts, thus increasing patient volumes. It alsoallows more leverage when negotiating payment schedules with managed care payers.There are different approaches to improve documentation of medical notes in a patient’s chart.Educating and providing support to the physicians is most important. Physicians areoverwhelmed with the job of caring for the patient while providing the highest level of care. Thepart of documenting may not seem as important. With knowledge of the importance of theirdocumentation, the physicians would be more aware of what they document. Having adocumentation specialist can also focus on improvement of revenue capture. Charge RevenueSpecialist review the chart documentation, diagnosis, and charges billed. If the documentationdoes not provide adequately support the diagnosis and charges or there are charges missing,querying the physician would be done. Using an electronic health record system can also helpsimplify the process of documenting. The system is formatted to prompt the physician for morespecified details. The EHR also has a voice recognition device. This can be used, and thedocumentation is automatically received in the patient’s chart.In addition to decreased revenue, improper documentation has other consequences. If a medicalchart is audited by an insurance company, and documentation is insufficient for the chargesbilled, the physician and facility can be fined thousands of dollars. Lack of information can beJacquelyn Schultz:potentially harmful when deciding on a treatment plan for a patient and carrying out a procedure.Inaccurate medical notes can lead to incorrect diagnosis, medical treatment, and cause a patientto be harmed physically.Not only is it a physician’s responsibility to provide the highest quality medical care to theirpatients, it is also critical that medical documentation is accurate and detailed as possible.Increasing revenue can allow the opportunity to purchase advanced equipment that can be usedto better treat patients. Audits can be decreased reducing fines and legal action. Overall properdocumentation is critical to increasing revenue and providing a patient the best care possible.