In utilizationreview (UR), he narrative summary of the review and status decision are the infrastructure that supports compliance, efficiency, defensibility, and scalability of the overall processes. Yet, in many healthcare organizations, UR documentation standards evolve organically rather than intentionally. Without a standardized approach, these summary notes can quickly become bloated, inconsistent, and inefficient. Reviewers frequently develop personal notation styles, leading to wide variation in the time required to complete and the overall usefulness of the note.
High-performing UR teams are moving away from lengthy, free-text narratives and toward structured frameworks that align with medical necessity criteria, reduce cognitive load for reviewers, and facilitate faster and cleaner quality audits. One of the most effective and scalable approaches is the AOP Format: Assessment, Objective, Plan.
The AOP Format in Action
-
Assessment(A): Clearly state whether the case meets criteria for inpatient or observation level of care and cite the specific guideline.
Example: "Meets MCG ISC M-230 criteria for Inpatient Admission: Myocardial Infarction."
-
Objective(O): Capture only the clinical data relevant to the applied criteria—labs, imaging, vitals, or interventions.
Example: "Troponin 0.82↑ (from 0.11), ST depressions V2–V4, on heparin drip and telemetry."
-
Plan(P):Note the plan and immediate next steps for the patient’s care.
Example: "Cardiology consult completed, plan for cardiac cath."
Measurable Impact of Structured UR Narrative Summaries
This concise format captures every medical necessity justification requirement while reducing documentation time by up to 60–70%. The clarity of AOP notes supports rapid review, audit readiness, and uniform training across teams, and can also lead to simpler training for new hires while maintaining strong defensibility when needed for clinical denial appeals.
Most importantly, reviewers can spend less time rehashing what is already in the medical record and instead spend more time applying clinical judgement where it matters: determining if medical necessity criteria is met.
Common Utilization Review Documentation Mistakes to Avoid
Even seasoned and expert reviewers can fall into habits that undermine efficiency and clarity. Having a structured framework for concise UR narrative summaries can help avoid these common missteps and timewasters:
- Restating the chart: Extract only the findings that support the criteria, rather than retelling the entire clinical picture.
- Writing as if the payer reads it: Payers rely on the medical record itself, not internal UR notes. Keep UR documentation internal and results-focused.
- Including irrelevant actions or commentary: Administrative steps, subjective impressions, or non-criteria-related details dilute the summary and add no value.
- Inconsistent formatting across reviewers: Variability creates quality assurance challenges and retraining burdens. Standardized templates ensure alignment and simplify the oversight process.
Common Questions UR Teams Ask When Adopting New Format
As with any potential process change, teams often raise thoughtful concerns when transitioning to a new workflow or format. Below are some common questions from utilization review teams and answers that directly address concerns:
- What if the case is complex and can’t be summarized briefly? Complexity does not require length. In utilization review, complexity lives in the clinical facts and applied criteria, not in the beefiness of the UR note. The AOP format forces prioritization of specific elements that drive the level-of-care decision. If there is data that does not support criteria, it does not belong in the UR summary. Structured brevity improves clarity, especially in high-acuity cases.
- Payers will deny if we don’t provide all of this UR documentation! In the vast majority of cases, the UR narrative documentation does not influence payer decisions –- the actual medical record does. Over-documenting in UR summary creates a false sense of reassurance while adding no true leverage during payer review. The effort spent crafting meticulously detailed UR notes in the hopes of payer approval could be better directed toward communicating with providers to confirm that the record accurately reflects the patient’s current clinical condition, educating providers on appropriate documentation improvement concepts, or simply completing more reviews per day.
- We have always done it this way –- why change now? Legacy practices often persist because they are familiar, and not necessarily because they are effective or efficient. As UR continues to mature and evolve as an integral party of the acute care healthcare industry, standardized, criteria-aligned documentation is becoming the industry expectation. AOP aligns UR documentation with modern administrative and scalability demands.
- Not every payer uses the criteria we have (InterQual or MCG), so we have to write long UR notes to ensure the payer has all the necessary information to approve.
Again, payers are not relying on the hospital’s UR review and summary note to make their own UR decisions. They refer to the medical records, which are sent via fax or web portal along with the notification of admission/request for approval, and they will refer to the clinical notes themselves, even when the UR details and notes are sent along too. Some hospital systems are even permitting payer UR staff to have direct access to their patients’ electronic health records (EHR) to reduce the burden of sending information back and forth via various manual methods.
From Administrative Task to Strategic Advantage
When implemented correctly, the AOP framework can refresh stale UR processes and support significantly improved productivity. As healthcare organizations continue to face increasing pushback from payers, tighter margins, and growing workloads to keep up with denials, disciplined workflows like the AOP framework can serve as a roadmap to greater success.
Explore how to implement an effective AOP framework for utilization review and watch for the final article in our series on transforming your UR culture.
