I was recently talking to someone about why EHR documentation is so awful to read. It’s because billing requires that the doctor spew out all this useless documentation in order to justify billing at a higher level (Side Note: Be sure to check out my previous post about Documentation by Exception Being the Dredge of EHR Documentation).

As I discussed this challenge with clinical documentation, this person told me that their doctors don’t mark everything as normal. Instead, they marked all of these systems as “No Complaint” (or something along those lines). Basically, the patient didn’t complain about that system. I didn’t really check it to know that it’s normal, but I didn’t notice anything abnormal and they didn’t tell me something was wrong.

Hopefully some of my readers that are billing experts can let me know if this type of documentation would fly in the US as far as getting reimbursed. Everyone I’ve seen has always marked it as normal. My guess is that for billing in the US just saying that the patient didn’t complain about a system wouldn’t get you reimbursed for evaluating that system.

However, the person I was talking with was not in the US and so he didn’t have to worry about the billing requirements that we have to worry about. My question to him was, “Then, why in the world are you documenting that the patient didn’t complain?” It seriously made no sense to me. You can basically assume that if you haven’t documented a system, then the patient didn’t complain about any system that’s not documented. Why would you clutter the medical documentation with all of these “Patient Did Not Complain.” That feels even worse than saying that everything was “normal” (unless we’re talking from a liability standpoint).

Maybe my trusty readers can give me some idea of why it would be worthwhile to document all of the “No Complaints.” Am I missing something? Is there some clinical value to it? Seems like a negative to me. Let me know in the comments if you know something I don’t know or if you agree with me that documenting “No Complaints” is a waste of clinician time and actually is worse than not doing it. I look forward to hearing your thoughts.

…read more

Source:: http://www.emrandhipaa.com/emr-and-hipaa/2015/06/04/no-complaint-vs-normal-in-ehr-documentation/