TIMELY CHARTING MEMO

TO: All staff
FROM: (Your Name) Health Records Specialist
DATE: (complete and current date)
SUBJECT: Timely Charting Memo
It is important that all healthcare providers working in this medical Centre understand the importance of keeping precise, accurate and complete patient records. All employees involved in any documentation are the guardians of the integrity of health records. Thus they become the advocates of the patient, and any transcription error they make can be very costly for the patient and the hospital. This is because accurate documentation ensures patient safety, provides a proof of program integrity and protects the health care provider.
Link between timely, accurate and complete charting with reimbursement
The value of precise and thorough medical documentation cannot be overemphasized. Accurate charting and conclusive medical records will make our practice effortlessly and quickly access patient’s records and make it easier to make pay claims and get reimbursement. It allows the entire healthcare team to have comprehensive records of patients’ care and progress in their condition as well as providing a means of performance improvement and risk management strategy (Christopher, 2007). Accurate, timely and complete health records are not only the backbone and proof of quality care we provide to our patients, but they also determine the category of medical services that we offer to our patients covered by the insurance firms and those that are not covered.

Errors arising from inaccurate or incomplete medical records affect reimbursement. Medical records should be updated promptly before billing to ensure timely and complete reimbursement. This should not disregard the fact that health professionals need quality time with their clients as this helps them gather essential medical information, develops a doctor-patient relationship and satisfaction in the long run (Welker, 2008). We should document the services rendered soonest to prevent forgetting some things as omitted services affect reimbursement and hospital revenue. W hen reimbursement is affected, patients are affected and so do insurance agencies, and this may affect our credibility and reputation and maybe lose our patients. In essence, inaccurate or untimely charting and wrong reimbursement affect us negatively.
How timely, accurate and complete charting affects billing
Our medical centre seeks to promote and uphold high standards of holistic care culture to our patients so as promote our services and prevent harm to our patients. Proper, timely and complete documentation is one aspect we can promote this as it provides evidence of what we offer. Consequently, what we offer should be correctly billed. Incorrect or incomplete and late updates on patients’ records lead to wrong billing. According to Welker (2008) wrong billing occurs when there is no documentation, duplicate billing, unbundling (separate billing for services intended to be charged as a bundle), charging services not rendered and up-coding (using more costly codes).
Accurate, timely and complete charting ensures that no additional services are charged and that nothing is omitted. Timely charting is paramount because all bills should be complete and closed before the patient is discharged. This ensures that dispute billing and reimbursement from payer organizations is done fast. It is also important because payer organizations have set time period for reimbursement or disputing a bill (Christopher, 2007). Unintentional omission of details regarding management of a patient results in under billing, therefore, loss of hospital revenue. Care should also be taken not to charge what is not done to avoid over billing the patient.
In conclusion, accurate, complete and timely documentation is a responsibility of every employee. It’s a vital component of patient care, quality improvement and provides a seamless functioning of our service provision system. So let’s promote this culture and protect the integrity of health information system through accurate and complete documentation, continuous workforce development and prompt corrective action.
References
Welker, K. (2008). Charting 101: Making Sure Your Documentation is on Time and Legible.
Today’s Hospitalist. Retrieved from http://www.todayshospitalist.comChristopher, R. (2007). Making Billing Strides by Improving Clinical Documentation, 19(12), 8.