Patients need to “document, document, document”

January 26th, 2018 / By Kimberly Lodge, RHIT, CCS

As I was sitting in the physician’s office filling out new patient paperwork and trying to document my entire medical and family history, my husband leans over and says “Just mark none. You are here to have your eyes looked at and the other stuff is not important.”

Of course, the HIM professional in me can’t help but say, “How can the provider get the whole picture if I do not give him all the correct information?” My husband does not understand how an auto-immune system issue can affect eye health. That got me thinking about how often patients “just mark none” and how doing this one little thing can impact our medical treatment in a significant way. 

As an HIM professional, I know that each provider (e.g. medical doctor, optometrist, dentist) must maintain a medical history of all patients being seen. Our past medical history can have a large influence on our current situation. The correct documentation of our medical history is an important tool that helps providers understand our whole health picture, along with our family history.

Healthcare providers need to do a better job of stressing the importance of “documentation, documentation, documentation” to patients.  Without complete history documentation, it takes providers longer to get to the root cause of some issues. As it turned out, my eye condition was caused by my auto-immune disease. If I had not taken the time to document my complete medical history, my provider may not have been able to associate the symptoms affecting my vision. This could have triggered additional and unnecessary tests, which would have resulted in more time to diagnose and additional out-of-pocket expenses in order to draw the correct conclusion.

As a patient, remember to “document, document, document” your past, social and family histories. Make sure the paperwork is filled out completely. A good rule of thumb: Request the forms ahead of time to complete at home and have ready at the time of your visit. This allows you time to thoroughly review and respond to the questions to ensure a clear picture of your medical history and any ongoing chronic conditions that may be impacting your overall health.

Kimberly Lodge is a coding analyst for 3M Health Information Systems.