Strategies to Address Medical
Records Violations Audio CD
Recorded June 17,
2004
Faculty: Barbara
Blackmond & Paul
Verardi
Medical records are primarily patient
care documents. But they are also legal, billing and compliance
documents. Too often, medical records violations – failure
to timely complete medical records, illegibility, inaccurate entries
or alterations – are viewed as minor infractions.
Those "minor" infractions
have major implications. Patients can be harmed. Alterations in
a medical record have been described by a court in a malpractice
case as indicating a "consciousness of negligence." Ongoing
performance improvement and peer review activities are rendered
ineffective. Poor documentation affects billing and raises compliance
concerns.
To make matters worse, the sanctions
that hospitals traditionally have imposed to attempt to achieve
compliance with medical records standards have often been ineffective.
If you have been plagued with medical
records documentation problems, join Barbara Blackmond and Paul
Verardi as they discuss:
Timely and Legible Completion
- Why is this important?
- How can you get buy-in? What's in it for the
physician?
- Legibility policy
- Educate the masses and the outlier practitioner
- Medicare
- JCAHO
- State regulations
- Legal (defense of claims)
- Patient care – communications among health care team
- Carrot and stick approaches to enforcement,
including:
- "Rewards" for good performance
- "Automatic suspension"
- "Automatic relinquishment"
- Letters of Counsel
- Fines
- Meeting with the MEC
- Attendance at a course
- Hiring a "scribe"
- Grounds for discipline
- Reportability of sanctions to the Data Bank
Alterations
- What is an alteration as opposed to a correction?
- Define authentication
- Policy on how to handle corrections and additions
(or include in rules & regulations)
Audio
CD: $195
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to
supplementary materials.
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