FIVE TIPS FOR MEDICAL DOCUMENTATION YOUR LAWYER WANTS YOU TO KNOW (AND FOLLOW)

By Angie Cameron Smith, Burr & Forman, LLP

Good documentation is important for many reasons: continuity of care, compliance, and risk management to name a few.  Documentation supports payment for services but can also form the basis of medical malpractice cases, whether it be lack of documentation, improper documentation or poor documentation.  Therefore, it is important to revisit best practices on a regular basis to protect providers from documentation pitfalls. 

1. Timely documentation and signatures

It seems elementary that a provider should timely document in a patient’s medical record, but one of the first issues that comes up in compliance audits (Medicare, Medicaid etc.), is whether there is timely documentation in the medical record.  In some instances, being timely may require a signature before a service is rendered; in other cases, the documentation should be done at the time of the encounter. It is important to document timely because it is a contemporaneous recording of the provider’s assessment.    

Signatures on medical documentation or orders can create significant liability because it is an essential element for payment and compliance.  For instance, Medicare has specific signature requirements, including:  (1) must be for a service ordered or provided by the provider signing; (2) must be handwritten or electronic, and (3) must be legible but can be confirmed through a signature log or attestation.  Neither Medicare nor Medicaid accepts stamped signatures unless the provider can establish an inability to sign due to disability.  We have often used signature logs and attestations in audits to establish the provider rendered the service, but it is preferable that the signature meet the requirements without the need for additional support.  Medicare also states that you cannot “add late signatures…beyond the short delay that happens during the transcription process.”  If a signature is missing from medical documentation (not orders) an attestation from the provider may render it valid.  

2. Follow your documentation policies  

Although there may be documentation requirements dictated by certain payors, a provider should also be mindful of any policies that a particular facility, practice or group may have regarding documentation.  Review your facility or practice policies with regard to documentation.  It is surprising how often there is a policy in place that addresses an aspect of documentation, and no one is following it, usually because the provider was unaware of it.  This can be very difficult to overcome when defending lack of documentation if a policy says the documentation should exist.

3. Need to make a change – use an addendum rather than editing an existing record

There may be times when a provider has created a timely entry on a patient, but sometime later, the provider recalls that he/she did not include a detail about the evaluation or treatment or encounter.  It is important in the age of electronic medical records that when editing, adding or updating an entry, that it be done as an addendum to the original entry rather than changing an existing record.  Editing could be problematic for many reasons.  For instance, when defending a medical malpractice case, there is often a request for a HIPAA audit trail that shows who viewed the record, made entries in the record or edited the record.  If something was changed as opposed to an addendum, this creates the appearance of an attempt to improperly alter a medical record.  Therefore, it is best to create an addendum to an entry previously made with an explanation as to the purpose of the addendum.  Where you are have a paper record or chart, it is less of an issue because the original note should be available but it is still important to initial any edits and not alter the original documentation.  

4. Copying and pasting, “cloning” 

For the most part, electronic medical records have made documenting medical evaluations and treatment more efficient, not to mention easier to read.  However, there are some efficiencies that should be avoided.  In some EMR systems, a provider has the ability to see information from a prior visit (see next tip).  As mentioned below, this can be great for continuity of care; however, if a provider copies the entry for review of systems or history and physical, and fails to edit it for the actual evaluation performed at the time of service, it can lead to problems.  From a compliance standpoint, such repeat/verbatim documentation can call into question whether the provider actually conducted the evaluation.  The same would be true from a liability standpoint.  It is unlikely that the exact same information would be gleaned from the patient on separate visits.  Therefore, a provider should not “clone” entries to create a new entry in the chart.   

5. Reviewing prior history or last visit 

Although not necessarily specific to documentation, it is important for continuity for care for a provider to consider or review information from any prior visit.  This often comes up in a failure to diagnose case where a provider failed to review a prior visit and on a subsequent visit, the symptoms complained of are exacerbated.  The patient’s attorney often argues that had the provider reviewed the prior visit, the diagnosis may have been different or the outcome may have been different.  A failure to review prior history does not necessarily lead to liability on the part of the provider, but it provides a narrative for a jury or arbitrator that a simple review of prior history could have led to a different outcome.  

Takeaway

Be mindful of documentation requirements necessary for payment/compliance, consider conducting self-audits of charts on a periodic basis to ensure compliance and ensure policies are up to date and reflect how providers are documenting.  

Angie Smith is a Partner at Burr & Forman practicing exclusively in the firm’s healthcare practice group. Angie may be reached at (205) 458-5209 or acsmith@burr.com.