Medical Records Perils and Pitfalls

[Note: Special acknowledgment to William Norcross, MD, Sara Fernandez Taylor, and Timothy Blanchard, JD, MHA, for providing pertinent information and support in creating this article.]

Communication: It’s a universal skill needed by all physicians. However, when we hear this word, we immediately think of verbal interaction. Only as an afterthought do we think of the medical record as a form of communication. Nevertheless, this written form of communication is of paramount importance when dealing with both concurrent patient care and review of past care.

Medical record keeping certainly does have downsides that we know all too well. It is time-consuming. It is likely the least enjoyable part of physician practice. It can be expensive, especially if the physician is paying for transcription or an electronic health record. And, for the majority of our charting that does not undergo scrutiny, there is no immediate or long-term behavioral reward. However, charting is necessary and does have many benefits related to patient care.

As primary care and specialty physicians contribute to care of an individual, the principal mode of sharing information is the written record, the chart note. The note is responsible for communicating information in a clear, logical manner with oneself and others (1,2): it can be used as the yardstick by which performance is measured; it can be used as a tool to improve care; and it is a legal document.

In our litigious society, managing risk has become very important in the healthcare profession. The quality of the medical record is essential in managing risk. It is the living record of the care that was delivered to a patient and can serve as the testimony documenting events in the past. In articles on reducing malpractice risk, the importance of thorough and proper documentation is constant across specialties (2,3,4,5). The medical record can be your best friend or worst enemy during litigation. A chart that is organized and thorough may be sufficient to answer queries on medical care delivered and lead to the dismissal of the case early in the evidence-discovery phase. It is also integral to defense attorneys’ ability to contest allegations and prove a doctor’s course of action (2,6).

The Medical Board of California (MBC) considers it unprofessional conduct for the “failure of a physician and surgeon to maintain adequate and accurate records relating to the provision of services to their patients” (California Business and Professions Code § 2266). The MBC also holds that “complete medical records are necessary not only to document the quality of patient care, but also contribute to quality by facilitating the continuity of care” (1). Medical care is complex and often delivered by multiple people in multiple locations. The MBC may assume that examinations, testing, or discussions that are not recorded did not occur, and the physician’s license may be put in needless jeopardy.

Medical care is complex and often delivered by multiple people in multiple locations. Coordination of care requires appropriate documentation in a longitudinal fashion with the members of the care team being able to locate information easily.

The medical record is also the document by which payers validate the level of charge. CPT code justification is based on the medical record. The Office of Inspector General (OIG) has stepped up enforcement in seeking fraud. Initial review that may trigger an investigation is based on the medical record and determining if the documentation justifies the payment. The OIG may pursue the Civil False Claims Act, and, if found guilty, the defendant is liable for treble damages — and a minimum $5,500 to $11,000 civil money penalty per claim (each CPT code) — potential government program exclusion, and potential criminal prosecution.

There are tools that can improve and facilitate the creation of health records. An easy-to-use and relatively inexpensive tool is voice-recognition software. If one dictates, they tend to include more information. After initial set-up, the software is relatively accurate in transcribing voice, including those who speak with an accent or with English as their second language. The more the software is used, the better the accuracy. Prices range from less than $100 (nonmedical version) to $1,500 (medical versions with recording devices). The most sophisticated tool that can be used to facilitate documentation is the electronic health record (EHR). While it is beyond the scope of this article to discuss the EHR in detail, it is recognized that all of American medicine will be required to use this tool in the near future. The United States Department of Health and Human Services has enacted many aggressive health information technology goals to implement universal adoption of this modality.

Much of the current work at improving patient safety involves the EHR. As information systems improve, data may be gathered that allows prospective and visit independent care (care that occurs when the patient is not in front of the physician) for patients. Physicians will have the ability to monitor the health information for patients in ways that could lead to improved care for the population of patients by monitoring parameters for chronic disease management and enacting treatment earlier in disease progression.

There are pitfalls of the EHR. While facilitating the creation of records with templates, caution must be exercised at review of the final note with careful removal of inaccurate documentation. The record that is “too complete” and without variation from patient to patient can be viewed as suspect as much as the incomplete record.

The UC San Diego Physician Assessment and Clinical Education (PACE) Program (7) provides competency assessment and education to physicians. The program receives referrals from state medical boards, hospitals, medical groups, and others for those with a demonstrated need for additional clinical education. The majority of requests for remediation that the PACE Program receives are in the area of medical records. The program provides education to more than 200 physicians per year on this topic alone — an indication of the scope of issues surrounding insufficient record keeping.

Medical Record Keeping: “Helpful Hints”

1. Create records in a timely fashion. Details of the care delivered may fade with passing time.
2. Create records that are legible.
3. Phone calls, emails, and other forms of communication with the patient must be recorded in the chart.
4. Document instructions given to patients including follow-up care and timeframe for return.
5. If you write records, do not squeeze in information by writing along the margins of the page. This writing is usually difficult to read and does not reproduce well. Continue writing on the following page or use addenda to add additional information to a chart entry. Always time and date the additional information even if it relates to an earlier time period.
6. Don’t erase errors. Cross out the erroneous entry with a single horizontal line, rewrite the correction, initial and date the correction.
7. Do not alter records fraudulently or after notification of intent to sue or review. Alteration of records is a violation of the law and may subject the physician to civil and disciplinary actions.
8. Each patient encounter should include: the date and reason for the encounter, appropriate history and physical exam, review of lab, X-ray data, and other ancillaries, assessment, and plan of care.
9. If using templates, make sure to have variable fields that can be customized to the individual patient.
10. When using an EHR, if you didn’t perform a specific task or exam, make sure it doesn’t show up in your documentation. Avoid the “over-documentation” pitfall.
11. Make sure that your documentation justifies your CPT coding.

The creation of medical records may seem mundane; however, its importance cannot be overemphasized. The medical record is one of the key items related to patient safety and improved care. In the end, when it is scrutinized, the medical record can be your best friend or worst enemy.

References:

1. McCready LA. Guidebook to the Laws Governing the Practice of Medicine. Sacramento, CA: Medical Board of California, Department of Consumer Affairs; 1998.
2. Nebel EJ. Malpractice: Love Thy Patient. Clin Orthop. Feb 2003(407):19-24.
3. Minkin MJ. Protect Yourself From Malpractice Suits. Fertil Steril. Mar 2004;81 Suppl 2:41-44.
4. Sullivan GH. Does Your Charting Measure Up? RN. Mar 2004;67(3):61-65.
5. Roberts RG. Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk. Fam Pract Manag. Mar 2003;10(3):29-34.
6. Allen J, Burkin A. How Plaintiffs’ Lawyers Pick Their Targets. Med Econ. Apr 24 2000;77(8):94-96, 99, 103-104 passim.
7. http://paceprogram.ucsd.edu