Blue Cross Blue Shield of North Dakota (BCBSND) would like to offer general education on documentation requirements. As you are aware, accurate healthcare documentation is vital for accountability, quality care, and compliance. Accurate records are essential for quality care and successful audits. A common industry saying you may be familiar with is “If is not documented, it didn’t happen” This statement highlights the importance of thorough documentation for patient safety and professional standards.
Documentation Requirements
Proper documentation in addition to safety is the foundation for a successful audit. BCBSND has published guidance for documentation requirements, and you find that detail in our provider manuals. Specifically, you can find them at the following locations:
In both references you will see the details below included among other requirements:
Documentation must be complete and legible and include at a minimum the following:
- Name of patient and date of birth on each page of documentation
- Date of service
- Date and signature of the ordering and/or rendering provider
- Chief complaint or purpose for visit or service
- All services provided, such as clinical assessment, examination, procedures performed, and equipment provided
- Treatment plans
- Orders for, intent of and results of all ordered diagnostic services
- National Drug Code (NDC) numbers on all drug codes and the use of rebuttable NDC numbers where applicable
- Include the following fields for each outpatient drug dispensed: – Total number of units of each dosage – Form – Strength – Package size by NDC
- The provider who is treating the patient must order all diagnostic services and must clearly document in the medical record his or her intent the specific test be performed. The provider who treats the patient is the provider who furnishes an evaluation and management service, treats the patient for a specific medical problem and uses the results in the management of the patient’s specific medical problem. Tests not ordered by the treating provider are not reasonable and necessary.
A final tip from an auditors’ view and what auditors look for in documentation:
- Accuracy: Documentation should be factually correct and reflect what occurred during the patient’s encounter.
- Completeness: All relevant information should be included, such as patient history, physical exam findings, diagnostic test results, and treatment plans.
- Relevance: The documentation should focus on information that is related to the patient's care and diagnosis.
- Timeliness: Documentation should be recorded promptly after the event or encounter to ensure accuracy and avoid delays.
- Clarity: The documentation should be easy to understand and free from jargon or ambiguous language.
- Conciseness: Documentation should be brief and to the point, avoiding unnecessary repetition or extraneous information.
- Legibility: The documentation should be clearly written or typed, making it easy to read.
- Confidentiality: Documentation should be protected and managed in a manner that ensures patient privacy.
We thank all of you for the continued support and efforts to ensure your patients receive the best care and subsequently document timely and clearly, ensuring patient safety and transparency in the care you are providing.
