10 Common Documentation Flaws


Stop and use caution before documenting your visit!


If you are not concerned about poor to mediocre patient care, getting paid or your license, read no further.  If any or all of these issues are of concern to you, keep reading.  Below are ten of the most frequent flaws in nursing documentation reviewed by the coders.  We know that these oversights and omissions are most often the result of a busy schedule or inattention to documentation because we know our clients.  State surveyors, Medicare contractors and agencies named with 3 letters and an Eagle (OIG, FBI, DHS, CMS, etc.) do not express any great interest in the underlying causes of poor documentation.

1.  No MD Contact Documented when appropriate

Many times, the MD is not called at the house due to time constraints or other issues.  When orders are received, they do not tie back to any communication in the chart.  Documentation of two way communication is critical to both sound clinical practice and payment.

2.  Contradictory Information

The 486 summary indicates that the patient lives with a daughter but the OASIS states the patient lives alone.  The OASIS data states that the patient becomes short of breath with minimal activity but the plan of care does not include shortness of breath in the functional limitation.

3.  Blind Adherence to Rules of Thumb

Somewhere along the way, nurses were told that they must always document on the primary diagnosis on every visit and follow the clinical pathway written by someone who has never visited the patient.  This has led to visit notes that read like, “Pt found on floor with scalp wound bleeding profusely.  Reports she fell yesterday and wasn’t wearing life alert button.  Taught to avoid soda and other concentrated sweets to manage blood sugar.”

4. Failure to Document Sensitive Information

A chart found in one the best agencies I know of had multiple notes reading that the patient complained of extreme pain.  The physician was notified after every visit with a fax and a copy of the med list.  No new orders were received.  The Director of Nursing explained that the patient had recently been the subject of an evening news story involving the sale of her pain meds to supplement her Social Security check. 

5. Missing the Little Stuff

When little things like vital signs, weights, and blood sugars are omitted from the clinical record, it causes problems.  A weight gain of ten pounds after two weeks of forgetting to weigh the patient is negligent but not as bad as forgetting the third week when the patient is hospitalized.  Most nurses take vital signs.  I spend many nights staring at the ceiling wondering why they aren’t on the chart.  Then I remember that I tend to write them on my arms and if I bathe before I chart, they are lost to the water supply.  What’s your reason?

6.  Missing the Big Stuff

Missing new orders, teaching on medications that have been discontinued and not notifying the MD for problems is more common than you think.  It is what feeds many malpractice attorneys.  It is why state surveyors might not trust anything you say during survey.  It is why nurses find themselves answering very difficult questions to the state board of nursing.  If you do not have a current care plan, refuse to see the patient until you have a verbal report.  Document the verbal report.  If you see a patient without looking at prior orders, shame on you.  If the prior orders taken by another nurse are not written and as a result you teach a patient to take a med that has been discontinued, write an incident report.  This is stuff that kills patients.

7.  Lack of Follow-Up

Lack of follow leaves gaping holes in the chart, and often, results in missed opportunities to provide better care to patients.  Consider a clinical record where you read one week that the patient has a doctor’s appointment the following day and that’s the last time it is mentioned.  Did anyone call to see if there was lab or new meds ordered?  It’s hard to believe but sometimes patients don’t tell you these things. 

8.  No Ongoing Medication Reviews

One of the easiest way to prevent re-hospitalizations, adverse reactions, and non-compliance with medication is to simply review all medications against the med list on each and every visit.  Every time a med is missing, a new med appears, or there seems to be confusion in dosing, there lies an opportunity to improve the care of a patient and to increase your level of skill ensuring payment. 

9.  Taking the patient’s word at face value

If a patient tells you they had a lab or diagnostic test and the results were fine, by all means document it.  Also call the physician who ordered the test and get the scoop.  The physician may have told the patient it was ‘fine’ or ‘no change since the last MRI’ but in the context of the specific patient, that same test could show degenerative disease, a low hematocrit or some other information important to support eligibility for your patient.  If possible, always get copies of the final reports for lab and diagnostic tests.

10.  Evidence of Ignorance

This sounds harsh but it is evident en masse in the clinical records reviewed by The Coders.  A new medication will be ordered specific to a disease that is not documented anywhere.  Eye drops for glaucoma, Zemplar for hyperparathyroidism secondary to renal disease, Invokana for Type II diabetes are all medications seen within the last week that have no corresponding diagnosis.  These meds both have serious side effects and teaching to ‘take medications as ordered’ will not help the patient avoid untoward adverse reactions or recognize side effects. 

All of these shortfalls in clinical documentation can be avoided by simply reviewing the charts.  The average time for a skilled nursing visit is 30 minutes and the average payment is equal or more to what nurses would make in the hospital.  This means that nurses have the time to review the clinical records, go to case conference meetings and call physicians.  If a nurse has ten fingers and a keyboard or two thumbs and a smart phone, enough information regarding medications is available around the clock.  Medscape has a great completely free app for mobile phones that has data that can be stored on your phone when you are away from Internet connectivity.

We all want to get paid.  If agencies don’t get paid, they have no money to pay consultants and coders and that reason to document well falls second only to improving patient care.


The Oxford English Dictionary defines weight as a body’s relative mass or the quantity of matter contained by it, giving rise to a downward force; the heaviness of a person or thing.

What the OED fails to mention is that weights are a critical measurement of overall health.  Symptoms of many diseases cause a person to shed weight.  Other diseases cause people to add body mass or weight.  It is a good thing to know what your patient weighs but more important to know how their weight changes over time.

Nobody gets concerned about weight loss of a pound or two.  Some of us are even thrilled when we notice the needle on the scale drift downwards a bit.  What we occasionally see when I look at episodes in their entirety is significant weight loss over the period of 60 days that is unexplained by diet or increased activity.  Nurses in the field sometimes fail to realize that the pound or two here and there over several weeks could point to an unresolved health issue.

It seems almost pointless to tell nurses to weigh their patients with congestive heart failure and yet over the week, we have reviewed numerous charts from different agencies where no weights were recorded.  This lack of attention to a basic measurement of congestive heart failure can and does lead to unnecessary hospitalizations. 

Sometimes, it seems that orders are written to prevent that burdensome task of notifying a physician of a decline in a patient’s condition.  A frail elderly woman weighing 103 pounds should not have to gain five pounds before the physician is called for orders.

What you may not know is how much this is costing you in terms of denials.  If you are a manager or administrator responsible for ensuring compliance to Medicare coverage rules, pay close attention.  

Observation and assessment is only a skill for three weeks unless there are credible findings that a patient is at risk for exacerbation.  For our purposes, an exacerbation is a worsening of a condition that involves changing the care plan.  In order to change the plan of care, the physician must be involved and new orders received.  Not every order must be for medications so be prepared to ask the physician if he needs lab or if you can make an extra skilled visit to check on the patient.

Each order you receive is like a ticket to ride the episode train a little longer.  Skills are provided and they are reasonable and necessary because there is documented information upon which decisions regarding care are made.

Without a documented information, the same skills may very well be provided without meeting the reasonable and necessary criteria.  Or, the weight gain may not be noticed especially if a different nurse sees a patient. 

None of this is anything that can’t be handled but the first step is to take it seriously.  The easiest way to do this is to begin weighing all patients.  Reserve written orders only for those patients with diagnoses or conditions that require weights to prevent unnecessary tags on survey in the event one is overlooked.  Habits are powerful things.  You will know the habit is real when you just don’t feel comfortable until a weight is documented.

Every patient should have a scale in their home.  No home health agency has ever filed for bankruptcy because scales were purchased for patient care.  It doesn’t even have to be a good scale.  It just needs to be the same scale in the same place at the same time each day. 

If you want to provide telemedicine but don’t have the resources, you can get the patients to call their weights into the voicemail of an unused line at your office by three o’clock every day.  Those patients who have not called can then be contacted by a part time student.  Imagine the delight of a surveyor when they see pretty little spreadsheets with weights on them and orders in the chart corresponding with increases or decreases.  Better yet, imagine the horror of the MAC reviewer who desperately wants to deny your claims because care was not reasonable and necessary and sees the very same thing. 

This low-tech telemedicine program also allows you to be more conservative with visits so you can attack weight changes like a SWAT team.  Go ahead and make daily visits for two to four days and cut out some of those visits where the patient is taught that one side effect of Lasix is frequent urination as if they didn’t know after taking it for a year or more.  The worst that could happen by scheduling conservatively while following weights telephonically is that patients will develop the habit of weighing themselves and become more compliant with meds and diet.  Then you actually save money by making fewer visits.  How cool is that?

Don’t stop with failure patients.  The sad fact is that some people don’t have enough to eat.  Your patients are confined to the home and may be too embarrassed to tell you that they do not have enough money for food.  Other elderly people seem to lose their desire for food and still more have side effects from medications that cause increased or decreased appetite.   Whatever the underlying reason, it can only be addressed if you know about it.  Assuming your patients are not wearing tight yoga pants and a sports bra during nurse visits, the easiest way to determine weight changes before harm comes to the patient is by weighing them.

You are nurses.  You can do this.  I promise. If you are one of those nurses who habitually forgets to weigh your patients, think of us for a change.  It will be so much easier to code charts if there are orders and exacerbations.  We’re not asking you to cause an exacerbation by slipping some salt in their tea or moving the needle of the scale up a few pounds.  We just want you find out about an exacerbation and get some orders while the problem is manageable and get paid well for taking good care of patients. 

Face to Face Answers

If you have not already taken the quiz on Face to Face encounter for home health, please do so by clicking here before continuing.  The answers are as follows.

When should the face to face encounter occur?

The face to face encounter should always occur within the 90 days prior to admission for home health services or within 30 days following the admission.  However, if a physician visit in the prior 90 days was not for reasons related to home health services, an additional visit is required related to home health services.

Who may sign the face to face encounter? 

The physician who orders home health services must always sign the face to face encounter. 

How can you  best assist the physician in the face to face process?

The best way to assist the physician is with education.  Not only do physicians resent the additional paperwork but if your agency is following the guidelines, there is a really good chance that you are competing against other agencies that complete the face to face documentation for the physician.  By educating your referral sources, you are also protecting them from inadvertently participating in fraudulent activity. 

A physician documents that a patient is confined to the home because they do not drive.  What should you do?

The correct answer is to visit with the physician and ask him to document why the patient does not drive. Assuming the reason that the patient does not drive is related to their health and not lost keys, the physician will hopefully understand homebound status a little better after your discussion.

Which of the following is not true about Face to Face Documentation?

Although it seems redundant as it is repeated so many times, a common reason for face to face denials is that the physician who certified the plan of care did not sign the face to face document. 

Which of the following is not true about Face to Face Documentation?

Yes, there are two questions that read the same.  This refers to question 8 and the only untrue answer is that the face to face should not be sent by the hospitalist while the referring physician sends the certification.  The face to face document is considered a part of the initial certification.

Everything else is true.  The physician may use drop down boxes in his or her software if they adequately describe the patient.  The entire face to face document may be computer generated and recent denials because the date of the encounter was not handwritten are erroneous on the part of the MAC. That is not a requirement.

Which is true regarding the physician narrative?

The correct answer is that it should contain the patient’s condition at the time of the encounter.  When the face to face documentation differs from the agency documentation, a denial may result.  For instance, a physician states the patient needs therapy and upon admission, the patient refuses therapy.  Because the patient is new anticoagulation therapy, the patient is admitted from services.  This type of discrepancy has resulted in numerous denials.

When is it acceptable to bill without a face to face encounter?

The only time it would be considered acceptable to bill without a face to face encounter would be if the patient dies prior to the 30th day and the agency can show that efforts were in progress for the patient to see the physician.  Please note we are not suggesting that you introduce your patient to the great hereafter if the patient does not go to the physician as planned.

When the referring physician is unavailable, the Medical Director may sign the Certification and Face to Face documentation.  (T/F)

False.  The only time the Medical Director may sign the face to face documentation is on those occasions when the patient was seen and referred by the Medical Director.  These referrals must fall under the confines of Stark and Anti-kickback laws that prohibit the sale of patients.

The face to face documentation is required on all patients admitted to a Medicare certified agency regardless of payor source.  (T/F)

This is actually a trick question because Medicare clearly states that only Medicare patients require a face to face document.  Try telling Humana that.  They are denying claims based on the language in their contracts with agencies that all Medicare rules apply to Humana patients as well.  Get one on everyone just to be safe.

The physician who signs the plan of care must also sign the face to face encounter. (T/F)

If you started this Face to Face adventure believing anything else and you now know better, you have not wasted your time. 

What is true about face to face documents prepared by a hospital physician who then handed off the patient to a community physician?

A final, often overlooked reason for denial is that any document that is used as the face to face document must be clearly labeled as the face to face document.  If the physician merely staples a discharge summary with all the pertinent parts on it to the plan of care, it will not suffice.  ALF’s often have a form that contains al of this information but if it is not labeled as a face to face, it will not count.  Finally, some hospitals have software that generate a document that looks like a face to face without being labeled.  This is an easy fix and I trust you will never be denied for an unlabeled face to face in the future.

How did you do?  Did you learn anything?  Feedback is always welcome and criticism is swallowed whole when offered with our best interests in mind.

The Coders want  you to get paid.  Together with our affiliated companies, HCMB billing and Haydel Consulting Services LLC, we are prepared to offer billing, coding and clinical consulting services tailored specifically to your needs.  Contact us today by email or click here to get your questions answered.  And be sure to subscribe to our blog so you won’t a single post.