With the number of clinical hospitalists still growing, more patients are under HM care, which puts hospitalists at higher risk for lawsuits. The goal for a hospitalist should be to take care of their patients, but at the same point make a defensible medical record. Plaintiffs’ attorneys look for potential red flags in the medical record. Potential red flags could be illegibility, omissions of date and time, criticism of other healthcare providers, vague terminology, abbreviations, delayed entries, inconsistencies between healthcare providers, corrections, and opinions about the patient.
The medical record is a legal document that is required by law and regulatory bodies. It serves as a communication vehicle for healthcare providers; it tells the patient’s story as well as the care that has been received. It is used for implementing quality-improvement initiatives, determining appropriate level of care, and research and education. It also is the most credible evidence in a legal proceeding. Inaccurate or incomplete documentation can mean serious trouble.
The most common documentation error is illegible handwriting. It is well known throughout medicine that if it’s not documented, it has not been done. At the same time, what is not readable has not been done. Electronic health records (EHR) have minimized this problem; however, EHR is not universally available, and documentation could include both electronic and handwritten entries.
Common sense dictates that all records should be legible, but it is surprising the number of progress notes that are illegible. Physicians are encouraged to write in black ink, so that the notes are capable of being photocopied. Some colored inks can run when they become wet. Also, all entries should include the full date, time, and the name of the physician, as well as their title and designation, which should be printed alongside their signatures.
Correction fluid must not be used in any patient records. Corrections should be made with a single line drawn through them, initialed, dated, and timed, so the error can still be read. All entries should be in a chronological order, with no spaces between the entries. Extra words should not be squeezed onto a line; a line must be drawn through any empty space at the end of an entry. Ditto marks should never be used. Use of glue is not permitted in the medical record, unless some special pages have tabs to allow sheets to be attached to the notes.
No paper should be removed from the clinical file, other than for purposes of photocopying, and those should be returned immediately. Each page of the documentation should be sequentially numbered; if the pages are kept in separate sections, make sure that is clear. Each progress note should have three unique patient identifiers: patient name, date of birth, and a record number. Most hospitals use sticker systems or printable progress notes, which have taken care of this problem.
Notes from various specialties, including nursing records, should be documented in the patient chart. If any of these include discussions held outside of normal working hours, those entry notes should clearly state the time and location of the discussions and state that the entry is made retrospectively.
Leaving space to accommodate late documentation never is a good idea. If the space is too small and subsequent documentation is squeezed in, an attorney could allege that the squeeze documentation was added to cover something up. If the space is too large, the blank space remains unaccounted for. When a late entry is made several days later, it should include a rationale for the delay. Unexplained late entries, along with erased or obliterated entries, are serious red flags.
The clinical content of a progress note should state in full a legible and understandable history. This should include a full assessment, including the positive and negative findings, interventions, and outcomes, as well as initial and ongoing assessments by each provider. Legible instructions should be included for all treatment therapies and medications. These records should be factual, consistent, and accurate.
When physicians disagree among themselves, criticism of that should not be on the record. In fact, this variance should be documented in the chart and the provider making this decision should clearly document the processes that led to the decision.
It is unwise to include abbreviations. In cases where abbreviations are necessary, they should be spelled out fully the first time. Institutional policies should be followed for appropriate abbreviations. Jargon, meaningless phrases, irrelevant speculation, and offensive or subjective statements should not be written. Labels to describe a patient as obnoxious, belligerent, or rude can lead to serious allegations. In fact, direct quotes should be applied on the record. The patient’s refusal of treatment should be documented, including the patient’s stated reason for refusal, if provided, and any action taken by the provider, as well as patient education and notifying the patient and their family. Patients who refuse to accept treatment recommendations might bear partial responsibility for a subsequent injury, which is known as “contributory negligence.”
Vague terminology should be avoided (e.g. “Cl urine” could mean colored urine, clear urine, or cloudy urine) as it can be subject to interpretation. Institutional policies should be followed for reporting incident reports. Peer-review processes should be noted; however, do not indicate in the chart that an incident report has been filed or an event report has been completed. This can serve as a red flag and could give the plaintiff’s attorney the right to access the record.
Documentation red flags should be addressed on a daily basis. Progress notes should be catered not only to providing an accurate record of the physicians’ thought process, but as an assessment of the patient, keeping in mind that if this case is called into court three or four years later, the record will speak for itself.
Deepak Pahuja, MD, FACP,
hospitalist, director of CME,
Erie Physician Network Hospitalists,
St. Vincent Health Center, Erie, Pa.,
CEO, Aerolib Healthcare Solutions LLC;
Priyanka Chadha, MD,
cofounder, Aerolib Healthcare Solutions LLC
DRG Accuracy Increases Medicare Reimbursement, Reduces Risks
Clinical documentation integrity (CDI) programs started in the 1990s. Most of the programs were experimental pilots that assessed the impact on physician documentation and quality.
In 2007, the Centers for Medicare & Medicaid Services (CMS) implemented the Medicare Severity Diagnosis Related Group (DRG). The focus of the DRG system was severity of illness and mortality rates. Indicators such as present on admission (POA) and hospital-acquired condition (HCA) were added the next year to identify conditions noted when a patient was admitted into the hospital.
Currently, the purpose of the CDI program is to optimize the DRG by capturing conditions through clear, concise documentation and coding. Accuracy in reporting DRG assignments will increase Medicare reimbursement and reduce compliance risks. CDI program popularity has grown because of careful consideration of the benefits of implementation.
Are we ready for the change? Launching a CDI program is not an easy task. It takes courage, tenacity, patience, and a great plan. The success of a CDI program depends on one key element: buy-in by physicians at your facility. Yes, physicians. Physician resistance is high for two key reasons: time and education.
A physician’s focus primarily has been the care of the patient, with time allowed to clarify their working or discharge diagnosis and maintaining their patients in the hospital setting. That’s where a clinical documentation specialist (CDS) comes in. At Civista Medical Center in Maryland, color-coded worksheets are printed and attached to the patient’s medical record. The purpose of the worksheet is to trigger the physician to write specific documentation.
Education! Education! It cannot be stressed enough. Healthcare is a team effort. To achieve accurate and concise documentation, physicians must be educated about the importance of documentation. Nonspecific documentation leads to nonspecific coding of the medical record. Therefore, the true severity of illness, mortality rate, and intensity of service goes uncaptured. The lack of specificity in documentation affects the quality of patient care, compliance risk, data integrity, and reimbursement.
The implementation of a CDI program can be successful by enlisting internal support at your facility, including administration, physicians, and such ancillary staff members as case management. A clear, concise plan that includes physicians every step of the way will be imperative.
Consider the many avenues you might have to implement your query system, either by paper or electronically. If the coding department does not own the concurrent CDI query process, make sure they are involved in the process of establishing the program. In addition, provide feedback to various facility departments about the impact the CDI program is having on quality, integrity, and reimbursement. Include an ongoing program to educate the physicians on ICD 9-CM, as well as the forthcoming ICD 10, for a smoother transition.
Karen Stanley, RN, MBA,
White Plains, Md.