Underdocument Care Failure

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Specificity of diagnosis, abnormal lab test and medication is often vital healthcare information in the medical record. Failure to document this information significantly slows hospitals from collecting the correct level of payment. Hospitals should not only target coders for performance improvement given that no level of accurate coding can overcome the lack of documentation. The Doctors that underdocument care and services provided represent the most significant opportunity to increase charge and reflect the severity level and provide adequate defense. When researched, Advisory Boards nationwide has uncovered multiple cases in which improved physician documentation has increased annual by 1.5 million. Accurate documentation should only

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