If progression notes by a physician are illegible, what is the best method for determining the documentation problem's extent?

Conducting a more detailed audit of Dr. Doe's patient records is the most effective method for determining the extent of the documentation problem. This approach allows for a comprehensive review of the physician's notes and can identify patterns of illegibility across multiple records. By evaluating the documentation systematically, health information management (HIM) professionals can pinpoint specific issues, such as whether illegibility is a chronic problem or if it was an isolated incident.

This thorough analysis can also provide insights into the potential impact on patient care and safety. If illegible notes hinder patient care, it becomes crucial to address the underlying causes—such as training needs or workflow issues—rather than jumping to punitive measures. Through an audit, HIM professionals can gather concrete data to formulate recommendations for improvement and enhance overall documentation practices.

In contrast, punitive actions such as suspending the physician or reporting them to the medical director without a thorough investigation may not address the root causes of the problem. These actions might lead to unnecessary disciplinary measures without understanding the extent and implications of the illegible documentation. Similarly, contacting a compliance hotline to revoke privileges can be excessively drastic, especially if the situation can be improved with proper audits and retraining. Thus, conducting an audit promotes a constructive approach that prioritizes quality