Shelly Mesure, MS, OTR/L
Can anyone guess what the title to this blog is stating? In the current culture of text messaging and abbreviations for everything, it can be a danger zone for medical documentation. As a consultant and seminar instructor, I come across a wide variety of documentation do's and don'ts.
Using abbreviations is a commonly practiced and uniformly accepted method of quick documentation tips. The issue becomes when we start to create and fabricate our own abbreviations. If you remember back to your medical terminology courses, we were taught many quick tips to better improve the efficiency of our documentation. However, nowadays, we need to be mindful of our target audience.
Who are we documenting for? It's very important to document the information for the inter-disciplinary teams and physicians; but in reality, we should be documenting according to what our claim reviewers will want to read.
As claim reviews continue to significantly increase, the demand for these job positions have created fewer skilled workers filling the openings. These workers, however, are the ones to decide if you've proven medical necessity and if you should be paid for your services.
I recommend thinking about your documentation and asking yourself, “Would a claim reviewer understand what I've written?”
Some abbreviations are very straightforward, such as, ↑ (arrow up) = increase. However, I wouldn't assume a claim reviewer would understand √ (check mark) to represent flexion. However, writing/typing the words flex/ext should get the point across.
Also, if we're trying to show progress, but document that patient was using the red band and is now using the green band, do you think your claim reviewer will know that's an improvement?
So, can anyone guess what my title stands for? I recently read a therapist's chart that kept using GTB throughout the entire claim. I started to doubt my abilities to understand medical terminology, so I finally just asked. The response I got was, “Oh, it's green thera-band.”
So, I said, “AYS” . . . Are you serious?