We educate a good bit about documentation of a proper assessment, use the acronyms M-E-A-T or T-E-A-M and still see skimpy notes with an “assessment” that doesn’t pass muster – from providers who, by now, should be on board with the concept. It occurred to us that maybe they don’t understand what is meant by the term or are unclear that their charting doesn’t meet the standard.
The Cambridge Dictionary online defines assessment as “the process of considering all the information about a situation or a person, and making a judgement.” Applying this definition to medical documentation, we know that clinicians obviously do make assessments of a patient’s medical conditions, but that thought process is not usually reflected in any detail on the progress note. And therein lies the biggest issue: synthesizing your split-second thoughts into a short but meaningful “blurb” about each medical problem.
Let’s begin with what is not an assessment of a medical condition.
Refilling medications. Although some would argue that a medication refill shows the condition is being managed, it’s not enough. After all, medication refills can be accomplished without a visit on that day. In some practices, med refills are independently transacted by staff within narrow parameters from the primary care practitioner (PCP). But ultimately, simply refilling a prescription doesn’t say a word about the thoughts leading up to the judgment to refill. A provider might argue that in the case of a diabetic medication refill, one (meaning a coder or regulator) should look at the embedded labs in the note to determine that the patient’s blood sugar is at the treatment goal, thus, no change in medication is warranted, and that this very string of thoughts occurred to the clinician which is why the medication was refilled – ergo, the condition was assessed. Sorry, but no. The provider should write something along the lines of, “A1c is at goal of under 6.5 and patient reports fasting sugars under 100. Continue current treatment plan. Refill XYZ.”
Ordering tests. This one is similar to refilling medications and the same thought process applies. Coders and auditors cannot infer from a test order that the condition has been assessed. Consequently, a description of the status of the condition, treatment goals and instructions given to the patient can fill in the blanks of the visit. After all, we know the PCP discussed something with the patient! Document a summary of that discussion: “Patient reports poor adherence to dietary plan and has been eating more fatty foods than usual. She will have a new lipid panel today and we’ll discuss medication and dietary issues at the next visit.”
Referral to, or management by, a specialist. Let’s consider the referral first. Proper documentation would require verbiage showing why the patient is being referred for this particular condition and what the specialist is expected to do. Put on your payor hat: providers are paid for doing something with the condition. If the treatment aspect is being transferred to another provider, why would a payor accept this diagnosis as part of the basis for a PCP’s payment (either FFS or capitated)? One could argue that in the capitated/risk adjusted payment world, a referral is part of “management” but the rationale is still missing. What did the PCP see or think on this day to prompt the referral? That’s what should be documented on the visit note!
If the condition is being managed by the specialist, as occurs with conditions like diabetic retinopathy, what assessment is the PCP making? Many of our clients raise the issue that they are not equipped to assess the patient’s retinopathy and we understand that. However, we assume the PCP receives consultation reports from the specialist; a blurb about the last consult, the treatment the patient is receiving from the specialist, any worsening of visual issues, reminders about tighter blood sugar control and/or explanations about the specialist’s role in treating the condition at least show the PCP’s management. Absent that, it’s best to issue the referral and not include the condition in the assessment since it hasn’t really been assessed.
Perhaps by looking at these three “not” assessments, providers will begin to understand the type of information expected for each medical condition on a progress note. Whether you remember M-E-A-T or T-E-A-M, each condition must have documented evidence of how the PCP is Managing, Evaluating, Addressing and Treating it. Don’t be like one provider many years ago, who asked, “You mean I have to assess every condition I list under the Assessment section of the note??!” In a word, yes.