May 2017
The Importance of Documentation: If it Wasn’t Documented, It Wasn’t Done
One of the foundational principles that is emphasized, but often forgotten, is that documenting the care provided to our shared patients/members is the important next step after providing excellent care. If it was not documented, it was not done. Whether you have heard that phrase or not, Blue Cross and Blue Shield of Texas recognizes the importance of adequate and accurate documentation on all visits, including Texas Health Steps visits. In fact, the Health and Human Services Commission (HHSC) published a letter to providers indicating that “missing documentation is the largest factor and the primary cause of records being reviewed and money being recouped.”
In past newsletters, the components to be documented have been reviewed in greater detail; however the provider HHSC letter lists the six checkup components that must be completed and documented in the medical record for reimbursement:
- Comprehensive health and developmental history
- Comprehensive unclothed physical exam
- Appropriate immunizations
- Appropriate laboratory/screening tests
- Health education
- Oral health referral
Review the HHSC letter featuring these six components on the Texas Health and Human Services website (under Current Notices). If you have questions about Texas Health Steps and documentation, contact your Texas Health Steps regional provider relations representative.