by Sydney Stuhrenberg, M.Ed, Product Specialist
In healthcare and behavioral health services, documentation is more than a record, it’s a safeguard. Accurate, timely, and compliant records protect providers, ensure continuity of care, and demonstrate accountability to payers, regulators, and clients’ families.
But documentation can also be a challenge. According to a 2022 report from the U.S. Department of Health & Human Services’ Office of Inspector General, 42% of audited claims contained errors linked to poor or incomplete documentation. These errors can lead to denied claims, compliance risks, and lost revenue.
So, what are the best practices agencies should adopt to stay compliant?
1. Document in Real Time
Research shows that waiting to complete documentation increases the risk of missing details. The American Health Information Management Association (AHIMA) recommends recording notes immediately after sessions whenever possible. Real-time documentation ensures accuracy and compliance with payer guidelines.
2. Follow Standardized Templates
Templates create consistency across staff and reduce the chance of omitting key information. Standardization also makes compliance audits smoother, since payers and regulators can quickly verify that required elements are present.
3. Capture Objective and Measurable Data
Regulators look for more than narratives, they expect observable, measurable outcomes. For example, in ABA and other therapy settings, session notes should tie directly to treatment goals and progress data.
4. Maintain Clear Audit Trails
Every change should be time stamped and linked to the user who made it. HIPAA and other compliance frameworks emphasize transparency and accountability in record keeping.
5. Protect Privacy and Security
The Health Insurance Portability and Accountability Act (HIPAA) requires agencies to safeguard client data at every step. Encryption, access controls, and secure storage aren’t optional, they’re essential to compliance.
6. Train and Support Staff Regularly
Compliance isn’t only about technology, it’s also about people. Ongoing training reduces mistakes, while support systems (like automated reminders or built-in compliance checks) help staff stay on track.
Where We Fit In
At Office Puzzle, we’ve designed our documentation tools around these very practices. From customizable templates and secure audit trails to built-in compliance reminders, our platform helps agencies reduce risk while making documentation easier for providers.
Because when compliance is streamlined, staff spend less time on paperwork and more time supporting the clients who matter most.