Documentation that Lacks

Documentation that LacksDocumentation. For some, it’s not a big deal, for others it leaves them with a feeling of dread.

From our early days in school, we’ve all heard the phrase, “if it’s not documented, it was not done”. In practice, documentation still means this and so much more. You might rephrase this as “if it’s not documented, you don’t get paid”.  Our documentation must support the level of work, and thus the billing we are doing. Therefore, if it’s not documented, chances are you will not get paid…or if you do, they can/will take it back when your charts are audited.

Documentation holds another very important purpose for healthcare providers. It not only provides a record of care to help you see next steps, but it also serves as a legal record of what happened during that visit – the patients story, what you heard, saw, and felt during the exam; your assessment and your plan of treatment for the patient. Five years into the future, this document is your memory of the visit.

Guidelines exist to help with us with documentation. There are systems and templates to help us quickly get the vital information into the chart. Articles have been written, courses have been taught. Indeed there is no shortage of information about documentation. And yet apparently the basics of documentation appears to remain a source of confusion for some.

Here is a real chart note I saw on a patient. Of course, I have  altered various parts to protect the identify of the provider and the patient. The essence of this note has been unchanged. It is written in the typical SOAP format.

cc. est. care

S. Comes in today to review meds. Needs asthma medication refilled. No wheezing. Wants more pain meds.

O.  A&O, NAD. Lungs clear. No ankle edema

A.  Chronic Pain, Asthma

P.  Albuterol refilled. Refer to pain management. Discussed quitting smoking.

When I saw this note, I was rather dismayed that this was written by a practicing healthcare provider. It matters not if this individual is an NP, PA or MD/DO – unfortunately, I’ve seen similar notes from all professions.  The bottom line is this note is completely inadequate.

Let’s get interactive here. In the comments area below, please share with our readers (seasoned professionals and students alike), what is missing from this example. How would you code this office visit (99211-99215)? What would you do differently?

Barbara C. Phillips, NP, FAANP is a professional speaker, author, clinician and business owner who provides business education, resources and support to Nurse Practitioners, Physician Assistants and other Advance Practice Clinicians — both for the employed and self-employed clinician. Additional information about Ms. Phillips is available at

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  1. Typically I see this type of note when s practice is overbookrd and foes not utilize an ehr. Lists chronic pain as DX without any mention of the WS for starters. Too much to type!

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