Responding to Medical Staff Reference Requests


Audio Conferences
		Disruptive Behavior and the Joint Commission's Sentinel Event Alert Effective Performance Improvement Plans
Audio CDs/MP3s
	AHP Potpourri Board Conflicts of Interest The "Borderline" Physician: Managing Performance Improvement for Those Who Can Improve (and Building the Legal Record for Those Who Can't) Charity Care Class Action Lawsuits Clinical Privileges: Tough Issues and Solutions CMS Clarification on Hospital Privileging CMS Issues Final Rule on 4 CoPs CMS: The New Guidelines for Informed Consent - Process, Policies and Forms Community Need for Physicians: How to Analyze, Prove and Document It Conduct Outside the Hospital: Are You Your Brother's Keeper? Conflicts of Interest on the Medical Staff Contracting and Credentialing: Bridge the Gap or Pay the Piper Corporate Bylaws: When Was the Last Time You Looked Yours Over? Credentialing and Medical Staff Records - Access, Control and Confidentiality Credentialing and Privileging Teleradiologists The Credentialing Process: Who is Slipping Through the Cracks? Credentialing the Aging Physician Credentialing Verification in the Trenches Criminal Background Checks for Physicians Deferred Compensation for ER Call Employing Physicians Series EMTALA and On-Call: Important New Changes EMTALA: The Final Rule and Regulations EMTALA Guidelines EMTALA Investigations: How to Survive Excess Benefit Transactions Exclusive Contracts - Strategies to Deal with the Shortage of Doctors Executive Compensation in IRS Crosshairs Fair Market Value The Feds Are Coming – Do You Know Where Your Physician Contracts Are? Forgoing Life Sustaining Treatment Fraud, Abuse & the OIG: A Look Back — A Look Ahead Free Speech or Disruptive Behavior? The FTC's Evanston Decision - Are Mergers Still OK? HIPAA and Credentialing HIPAA - Everything You Ever Wanted To Know — And Weren't Afraid to Ask HIPAA Investigations and Enforcement HIPAA Security Regulations Hospitalists: The Who, What and How The "Independent" Medical Staff – What Would It Really Mean? Investigations and Hearings — Should You Follow Your Bylaws? Maybe Not! IRS Final Form 990 The IRS is Watching YOU – Part I: Good Governance Practices for 501(c)(3) Organizations The IRS is Watching YOU – Part II: Exempt Organizations Executive Compensation Compliance Project Report It's Never Too Late for an Amicable Resolution — Alternatives that Can Protect Patients and Save a Career Joint Venture Series The Kadlec Appeal – Decision Against Hospital Reversed! The Limited English Proficiency Rules Low and No Volume Practitioners Malpractice Claims and Your Credentialing Process Malpractice Insurance Premiums: Helping Your Doctors Pay Managing the Disruptive or Difficult Patient Medical Ethical Issues - Right Choices, Legal Answers Medical Record Deficiencies: Practical Solutions to a Persistent Problem Medical Staff Integration Models for a Sustainable Future Medicare Physician Supervision and "Incident-to" Billing: What are the Rules? New MS.1.20: Stay the Course or Jump Ship? Must Hospitals Train Their Staffs to Bite the Hand that Feeds Them? Nonprofit Governance Audio Series: Legal Compliance and Public Disclosure Effective Governance Practices Financial Management and Fundraising On-Call Audit & EMTALA Update On-Call Problems and Solutions The Organized Medical Staff & Joint Commission Compliance:: Real Life Issues, Practical Solutions Panel on Nonprofit Sector Announces Principles for Good Governance and Ethical Practice Patient Complaints and Grievances – Time to Take Them Seriously Patient Safety and Quality Improvement Act: Proposed Regulations Paying for On-Call Services - the OIG Speaks Physician Behavior Physician Recruitment and Retention After Stark III Poliner: Court Upholds Jury's Findings Practical Solutions to Your Toughest On-Call Problems Practical Tips for Developing Medical Staff Leaders Precautionary Suspensions are to Protect Patients A Primer on Preemption: Incorporating State Privacy Laws into Your HIPAA Compliance Plan Protecting Peer Review Information Quality/Performance Improvement & Peer Review Best Practices Reconciling Conflicting Financial Interests of Physicians & Hospitals Recruitment Before Credentialing: What Were You Thinking? Resignation of Privileges to Avoid On Call Responsibilities Self-Disclosure & Government Investigation Sexual Harassment - It's Not Going Away! Does "Sham" Peer Review Really Happen? Sizzlin' Hot Credentialing Issues Specialty Hospitals and Gainsharing Alert! Stark 3.5? Proposed Changes in Inpatient Prospective Payment Rules Stark 2.5 - the Party's Over Stark Phase III Regulations ... They're he-e-e-e-e-e-re! Stark: Software/New Stark and Antikickback Rules Stark Violations in Your Medical Staff Office? Strategies to Address Medical Records Violations Take Control of Your Medical Staff Hearing Process Tax-Exempt Hospitals and Politics: Survival Guide for the Election Year Teleradiologists: Credentialing and Privileging Temporary & Locum Tenens Privileges Unanticipated Outcomes Disclosure and Medical Error Reporting

Medical Record Deficiencies:
Practical Solutions to a Persistent Problem
Recorded July 26, 2006

Faculty: Susan Lapenta and Monica Hanslovan

Medical records are primarily a means for health care workers to communicate about their patients. When a medical record is incomplete, inaccurate or illegible, the consequence to the patient can be devastating and the ensuing ramifications for the physician and hospital can be costly, if not career limiting.

The ability to bill for medical care also depends on what is included in the medical record. This means that medical record deficiencies can seriously affect the bottom line of an institution and trigger compliance issues.

And there is no denying that medical records are legal documents with significance beyond the hospital. The medical record is often a key document in any malpractice case. In malpractice cases, juries will consider not only what is included but also what is not included in a medical record.

Hospitals and medical staffs have long struggled with ways to address the persistent problem of medical record deficiencies. Traditional sanctions have been ineffective. New solutions are needed.

Susan Lapenta and Monica Hanslovan from Horty, Springer & Mattern and their special guest Dr. Elizabeth Grace, Medical Director from the Center for Personalized Education for Physicians ("CPEP"), discuss various medical record deficiencies and practical solutions. They discuss:

First Things First: Know the Rules!

Medicare Conditions of Participation, JCAHO and AOA Medical Record Standards: What is Required and What to Do When the Standards Differ?
State Law Requirements Cannot Be Forgotten

Understanding the Major Medical Record Deficiencies, Legal Standards and Safety Hotspots

Timeliness
Legibility
Verbal Orders
History and Physicals
Progress Notes
Abbreviations
Alterations to Medical Records
Inappropriate Entries
Inadequate Documentation for Orders Pertaining to Controlled Drugs

Electronic Medical Records - Are They the Cure or an Easier Opportunity for Abuse?

Practical Solutions to Try

Educate Your Entire Staff about Medical Record Issues (and Give CME)
Get the Malpractice Carriers Involved
Rewards for Good Performance
Letters of Counsel
Meeting with the MEC
Fines
Try a Course to Ensure Compliance

What to Do When Neither the Carrot Nor the Stick Approach Has Worked?

Automatic Relinquishment of Privileges
Automatic Resignation

Audio CD: $225

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