Tell the Patient’s Story: Clinical Documentation in PDGM

Clinical documentation plays many roles within healthcare. It validates the patient care provided, supports coding decisions, and facilitates claims processing, billing, and reimbursement. But at its core, clinical documentation works as a narrative in telling the patient’s story – where the patient has been, what they are going through and what the future holds for them. Under home health’s PDGM, telling the patient’s story with clinical documentation takes on a greater importance than ever.

Tell the Patient’s Story 

Accurate clinical documentation is a description of the patient that accurately reflects their condition, abilities, and the environmental situation at that point in time. Clinicians must be sure documentation supports the developed plan of care, accurately describes patient outcomes and reflects clinical competence. An assessment strategy should not reflect an interview process. Instead, it should effectively reflect three key factors:

• Interaction
• Observation
• Measurement

A patient’s story begins with a plan of care that is appropriate for the patient’s diagnosis, ensuring the patient or caregiver is following the plan of care and creating a medical record that reflects the same. Only a few provide care to the patient, while everyone else merely reads the story. For this reason, the story must have a beginning, middle, and end. Clinicians need to record the information at the point of care and not hours or days later. Recording the data at the point of care also allows for interaction with the patient which also increases patient engagement, replacing the “interview” with “assessment.”

The Cost of Inaccurate Data 

Inaccuracy in clinical documentation can have far-reaching impacts. The effects can be felt at the patient-care level, in the individual home health agency and on a larger regulatory scale. Some impacts of inaccurate or insufficient documentation include:

• A poor plan of care (too many visits, not enough reimbursement)
• Inaccurate patient health profile
• Potential for poor outcomes
• Flawed data set from which others may base their decisions
• Major financial challenges, such as lost revenue, ADRs and denials

Support Your Team 

People, processes, and technology are the three resources that work together and drive quality clinical documentation. Home health agencies must ensure clinical competence as they deliver quality care. Clinical competency includes the assessment and documentation of that assessment. The clinician’s responsibility is to acquire and maintain professional competence, but an agency’s leadership is responsible for providing an environment that is educative and conducive to competent practice.

Everyone in the agency should know the meaning of accurate clinical documentation, as well as the goals and expectations for staff. Be transparent with data outcomes to staff and provide the education needed to increase accuracy as a shared responsibility for improved quality. The more an agency emphasizes the importance of “telling the story” of their patients, the better the outcomes will be for everyone involved.