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Of Dementia and Documentation

in  Documentation    coding    medical billing    notes    dictation  

Of Dementia and Documentation“I meant every word I didn’t say.”  -Jimmy Dunne

My mother is 90 and showing early signs of dementia.  She forgets things.  She occasionally suspects she has been robbed, or insists she is being singled out for persecution from among the several dozen fellow residents at the senior living apartment complex where she lives.  She lives on her own, sans official assisted living, and while her stove and oven have been disconnected (she set off her smoke alarm after forgetting she had something in a pan) she is allowed a microwave and coffee maker.

Yesterday my sister took her to see the doctor.  While mom spoke with the doc my sister talked with the social worker.  This is good because with my sister or me present, mom tends to lie to doctors about how much wine she consumes.  She used to lie about cigarette smoking, but we think she has finally given that up.  We think.  As part of the diagnostic interview the doctor asked my mom to list all of the words she could think of that begin with the letter, “F.”  That’s right, “F.”

Now, despite being a lifelong Democrat, mom is a bit of a conservative when it comes to social behavior.  A stout Lutheran since the days of the Apostle Paul, she swears only when she is sure there will be no witnesses, including God.  So, naturally her immediate response was, “I can’t say that word!

“What word is that?” asked the doctor.

“I just can’t say that word,” insisted the old gal.

“It’s ok, Dawn,” replied the doc.  “I know we’re thinking of the same word, so we’ll count it without you having to actually say it.”

On the way home, almost giggling, mom related the account to my sister, repeating the story several times.  Finally, she blurted, “I can’t believe the doctor and I were both thinking of ‘fart!’”

My sister almost drove off the road.

Documentation is kind of like that.  Most providers do a pretty good job of accurately recording the important details of patient encounters, but on occasion (according to the coders with whom I work) their dictation can be unclear.  Wooly documentation can lead to erroneous interpretation and faulty coding, which potentially makes for inaccurate billing.  Providers should never assume the coding staff will know what they were thinking, or what they meant to convey.

I can't say if the aforementioned "F-word" made it into mom's medical record, but case in point, check out these gems from doctorslounge.com:

  • She stated that she had been constipated for most of her life until 1989 when she got a divorce.
  • The patient was in his usual state of good health until his airplane ran out of gas and crashed.
  • She is numb from her toes down.
  • Exam of genitalia was completely negative except for the right foot.
  • The patient was to have a bowel resection. However, he took a job as stockbroker instead.
  • On the second day the knee was better and on the third day it had completely disappeared.
  • Patient has chest pains if she lies on her left side for over a year.
  • He had a left-toe amputation one month ago. He also had a left-knee amputation last year.
  • By the time he was admitted, his rapid heart had stopped, and he was feeling much better.
  • The patient is a 79-year-old widow who no longer lives with her husband.

Humorous examples aside, fair reimbursement requires accurate, clean claims, and that doesn’t happen without precise documentation.  Let’s all work together to get our claims right the first time and avoid payment delays and denials.


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