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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