Surgeons and proceduralists are often faced with a high volume of patients, complex cases, and demanding schedules. In this context, it can be challenging to complete and close patient notes in a timely manner. However, closing patient notes is not only a legal and ethical obligation, but also a crucial factor for ensuring patient safety, quality of care, and workflow efficiency.
This article will explain why doctors should expedite closing patient notes, especially when planning to order or schedule a procedure, and provide some tips and best practices for doing so.
Closing patient notes is the process of finalizing and signing off on the documentation of a patient's medical history, physical examination, diagnosis, treatment plan, and follow-up instructions. Closing patient notes has several benefits for both the doctor and the patient, such as:
- Improving communication and coordination among the care team, other health care providers, and the patient.
- Reducing the risk of errors, complications, and malpractice claims.
- Enhancing patient satisfaction and trust.
- Facilitating financial clearance and reimbursement
- Meeting regulatory and accreditation standards.
Why Closing Patient Notes Is Urgent When Planning a Procedure
Closing patient notes is especially important when a surgeon plans to schedule a procedure for a patient. A procedure is any intervention that involves the manipulation, removal, or alteration of a body part, such as a surgery, biopsy, or endoscopy. Procedures require informed consent from the patient, which means that the patient has been adequately informed about the risks, benefits, alternatives, and expected outcomes of the procedure, and has agreed to undergo it. Closing patient notes before scheduling a procedure ensures that the informed consent process is documented and that the patient's current condition and preferences are reflected in the treatment plan. This can prevent potential delays, cancellations, or disputes that may arise if the patient notes are incomplete, inaccurate, or outdated.
Additionally, insurance companies continue to require extensive documentation to show that conservative (i.e. cheaper) interventions have been attempted before planning more extensive or invasive ones. This means that the financial clearance process will be delayed, if not completely derailed, by incomplete or missing documentation. Procedures in the OR, advanced imaging, and even office procedures that previously did not require prior authorizations are now requiring this level of scrutiny. Some plans will require a Peer-to-Peer or a written appeal for a denied prior authorization. In most cases, the trigger for this response from the plan is a mismatch between the planned procedure and the diagnosis or indication used. Even using a less specific diagnosis code is enough to cause an exception with the payer’s algorithm and will delay the financial clearance of the procedure.
A “Best Practice” is to stay connected to the information provided here each month by UTMB Revenue Cycle Coding and Pre-Service Clearance. We are always happy to meet, in small or large settings, with any and all providers and support staff. Reach out to schedule some time today!
The RCO Coding Education Team invites you to contact us to schedule large group, small group, or 1:1 training. We are dedicated to the education and success of all UTMB providers. Please contact the Revenue Cycle Coding Education Team to ask questions or schedule a meeting. We are here to help! Email the Coding Education Team. |