Good Documentation Is
- Accurate
- Objective
- Timely
- Relevant to the service provided
- Consistent with the treatment plan
- Compliant with payer and organizational requirements
Use Observable Language
Describe what occurred rather than making unsupported judgments. Distinguish direct observation from caregiver report or inference.
Common Problems
- Late notes
- Copy-forward text that does not reflect the session
- Missing data or required elements
- Subjective or stigmatizing language
- Documentation that conflicts with billed service
- Unapproved abbreviations
Corrections
Follow organizational and payer procedures for correcting documentation. Do not delete or obscure records in ways that compromise the audit trail.
Privacy
Use approved systems and protect PHI in accordance with organizational requirements.
Important Note
This public guide is educational and does not replace company policy.
Next Step
Internal staff should follow The Dailey Institute’s current documentation policies and payer-specific requirements.
