Why Documentation Matters in Urgent Care: 3 Considerations

It’s an exciting time to be involved in urgent care: we’re operating at the precipice of consumer-driven healthcare and leading the way in tailored health services. There are many factors to consider in order to stay ahead in this highly competitive and rapidly growing market, including the right approach to documentation. Documentation has the ability to impact a number of upstream and downstream outcomes, and the right documentation systems and processes can promote an overall better patient experience, improve throughput, and optimize reimbursement.

To ensure optimal outcomes from documentation, urgent care centers should consider these three areas:

ICD-10 Preparation

While the buzz around ICD-10 has focused on the complexities of coding, it’s important to consider the substantial role of documentation in this transition. Coders can only code what has been documented, which means much of the ICD-10 burden will fall on clinicians. Clinicians need documentation tools that will support the increased level of specificity required for ICD-10 without decreasing their productivity or interrupting their workflow. In the absence of rapid and accurate information capture, clinician productivity and efficiency will decrease, delays in the billing process will occur, and profitability will suffer.

Consider otitis media, one of the most commonly seen pediatric conditions in the urgent care setting. Under ICD-9, documentation and coding of this diagnosis is straightforward. With ICD-10, clinicians must provide more specificity, including whether the condition is in the right or left ear; if it is acute, recurrent, or chronic; serous or suppurative; and if tympanic membrane perforation is present and, if so, where the perforation is located. Protocols that support the physician in documenting the specificity required by ICD-10 are critical in order to ensure efficiency, productivity, and optimized reimbursement.

Quality Patient Encounters and Risk Mitigation

Documentation not only makes it easy for a physician to capture the right information for reimbursement and follow-up, but it also provides clinical content that facilitates high-quality patient encounters. When tools and procedures are optimized, providers can easily and efficiently document the care encounter while interacting with the patient. Documentation can serve as a useful tool to facilitate quality care, and should not be a burden during the patient encounter.

Detailed, urgent care-specific clinical documentation results in a complete medical record that tells the full story of the patient encounter. Documentation tools that illustrate the cognitive process used to achieve the differential diagnoses result in a clear picture of the other conditions that were considered and ruled out in order to arrive at that diagnosis. These tools can also help clinicians keep alternate diagnostic possibilities top-of-mind, and minimize the possibility that a relevant diagnosis is overlooked. The end result is an accurate and detailed medical record that helps support medical decision-making and mitigates risk.

Digital Connectivity

While some urgent care facilities may resist implementing full EHRs because of the significant financial investment required, digital connectivity should not be overlooked. Urgent care presents unique challenges because a patient’s past history may not be completely clear or readily available, making it difficult to put current findings into context.

As patients increasingly expect digital connectivity and information sharing between providers, the ability to securely store and share records with the next provider in the care spectrum or a patient’s primary care doctor becomes critical. Documentation tools can facilitate information sharing with other providers, which will contribute to patient experience quality and improved patient outcomes.

Documentation is a necessary evil. Nobody likes to document, but leveraging documentation can lead to improved outcomes for both the care continuum and the urgent care center’s business goals and objectives.

Robin Shannon, RN, MN, MBA is vice president and general manager of documentation solutions for T-System.

About Robin Shannon, RN, MN, MBA

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