While nursing is definitely a hands-on profession and one of the biggest benefits of the job is getting to make a real difference in the quality of life for your patients, documentation is just as important.
There's a saying in the medical field that if it wasn't documented, it didn't happen. Thorough, accurate documentation is important not just for ensuring quality of care for patients but also to help support proper billing and collections.
Learn how what you put in your nursing notes can have a big impact on healthcare billing and some tips for making them as accurate as possible.
Why Accurate Nursing Notes Are Crucial
As a nurse, you already know that quality patient care comes down to providing the right thing at the right time in the right dosage. Whether it's medications, testing or keeping an eye on a patient's vital signs post-surgery, accuracy is key. This same level of attention to detail should be provided in your nursing notes as well.
Nursing notes play a critical role in the documentation process that supports accurate billing and collections, and ensuring notes are "clean" — which means that they have been coded correctly — can help decrease the frequency of claim denials, which are an issue for both patients and the facilities providing care.
A claim being denied can mean that the facility has to put a great deal of effort into recoding and refiling the claim or trying to appeal it with the insurance company. And sometimes, this doesn't work, which means the facility doesn't get paid for the services at all.
As Seth Turnoff of Custom Medical Services states, "One of the most crucial areas that nurses can support in ensuring reimbursement is to ensure that all claims being created are 'clean' claims by proactively ensuring that all procedure codes are transcribed correctly. The chances of a claim being paid on its first submission increase exponentially if all entry information is entered correctly, which too often is not the case."
Even in cases where it wasn't an issue with the nurse's documentation that causes the claim to be denied, accurate nursing notes can be a big help when it comes to appealing denials such as those for "lack of medical necessity." Your notes can also help patients get approval from insurance companies that require pre-authorization before they will pay for some procedures and services.
Tips for Keeping Nursing Notes Accurate
Keeping nursing notes accurate comes down to noting everything — and that does mean everything — that's happening with the patient and the care services provided and ensuring that your notes reflect the facts and are easy for someone else to read and understand. For the best nursing notes, follow the SOAP method.
Subjective : This is the section where you focus on documenting how the patient feels or what they're experiencing. Examples could be everything from overall disposition to pain levels. Key points to record here include the actual feeling, how long it's been going on and if anything has helped or made it worse.
Objective : Here you're putting in any relevant test results, vital signs or factual observations. Make sure to write down the appropriate units for test results or medications administered as well as any special circumstances surrounding them, such as time of day or whether they were taken with or without food.
Assessment : In this part, you record what the diagnosis or assessment of the problem is. It should include a clear diagnosis (if available) that corresponds to the appropriate medical code, as well as whether the condition is chronic, acute, etc.
Plan : This section of the nursing notes details what the next steps will be. This could include anything from notes for the nurse at the next follow-up visit to a change in prescribed medications to a plan for further testing and scheduling future procedures.
Putting these tips to work in your nursing notes during your next shift can make it easier for the hospital or other healthcare facility to accurately bill patients' insurance for procedures and increase the likelihood that claims are processed and paid correctly.