7 Dirty Words of Documentation: "Because We've Always Done It That Way"-Webinar Recording

Video Transcription

Video Summary

Jill Young discusses the evolution and challenges of medical documentation, focusing on the "seven dirty words of documentation"—old habits tied to historical guidelines that hinder current efficient and compliant charting. She reviews major shifts in documentation standards from 1995 and 1997 to landmark changes in 2021 and 2023, which emphasize medically appropriate history, exam, and especially medical decision-making elements to determine service levels. Young stresses the necessity of breaking outdated practices like over-documentation and copying extensive templates ("note bloat") that do not reflect the unique patient encounter. She highlights key compliance aspects, such as avoiding blanket comorbidity counts without addressing them, differentiating tests ordered versus reviewed, and adequate documentation of prescription drug management beyond merely refills. The importance of narrative, specific language—using terms like "acute," "severe," or "progression"—is underscored to demonstrate clinical complexity and support coding levels. Young also describes new time-based coding rules, including counts of face-to-face and non-face-to-face care on the service date. Her primary message encourages clinicians to adopt streamlined, patient-specific documentation that aligns with current rules, reduces administrative burden, enhances audit defensibility, and ultimately saves time to improve care.

Keywords

Value-Based Reimbursement

Fee-for-Service

Accountable Care Organizations

Medicare Shared Savings Programs

Patient Outcomes

Care Coordination

Osteopathic Medicine

Healthcare Technology

medical documentation

documentation challenges

seven dirty words

documentation standards

medical decision-making

note bloat

compliance in charting

narrative documentation

time-based coding rules