Documentation in Order to Manage Risks: Part I

  • By: VALA
  • On: 11/09/2020 08:34:53
  • In: Law
  • Comments: 0
The following article is about the necessity of documentation of care provided, regardless of practice setting.

Please do not hesitate to contact us with comments, questions, or requests for additional information.
Elizabeth E. Hogue, Esq.
(877) 871-4062
There is an old saying among health care providers: “If you did not document it, you did not do it.” Harsh as this adage may sound, it is still generally true. Providers usually do the right thing, but may fail to document the quality of care that was rendered to patients. When care is subsequently questioned, practitioners are in a much more vulnerable position than they would have been if treatment had been properly documented.
The Centers for Medicare and Medicaid Services (CMS) has made it clear that it is the responsibility of practitioners to provide complete documentation of services rendered. When documentation is incomplete, regulators may conclude that appropriate care was not rendered and that providers may have engaged in fraud and/or abuse. Practitioners must be especially meticulous with regard to documentation of: 
  1. Monitoring and observation of patients
  2. Physician responses to reports of changes in signs and symptoms
  3. Receipt of laboratory results within appropriate time periods
  4. Patient falls
  5. Additions or corrections to documentation in patients' charts
Staff members have a responsibility to monitor patients for changes in signs and symptoms, and to report them to patients' physicians. Staff must perform an adequate initial patient evaluation. They are also required to continuously monitor patients for changes in their conditions. Staff must report changes in patients' conditions as the situation warrants. When patients' conditions worsen because staff did not make reports within an appropriate period of time, the issue becomes whether the problem should have been detected earlier.
The law does, however, apply a standard of reasonableness to such situations. The frequency of staff observations, therefore, is determined by the patient's individual needs, the frequency of services, customary practice, physicians' orders, and providers' policies.
Beyond listing the factors that will be considered, it is impossible to establish hard and fast rules for reasonable conduct with regard to monitoring and observation. Determinations of reasonableness in these areas will be made on the basis of individual cases.
Some staff members behave as though their only obligation is to report changes in signs and symptoms to physicians. Staff members are all too familiar with situations in which the patient's condition changed and was clearly worsening over a period of hours. The patient's attending physician would not, however, come in to see the patient or respond to staff, especially if called during the night. In some instances, the patient died, perhaps as a result of the failure to receive adequate care.
Providers must recognize that they have an obligation to obtain and document a response from patients' physicians whenever they report changes in patients' conditions. In other words, they cannot throw reports to physicians “down a black hole.” When physicians are unresponsive despite repeated requests for assistance, staff members have an obligation to do whatever is necessary to make certain that patients receive needed care. This obligation may be fulfilled by calling another physician, such as the Medical Director, for help or transporting the patient to a hospital.
Providers must establish and monitor a system for making certain that patients' laboratory results are received on a timely basis and that physicians are notified of abnormalities. It is unacceptable practice for staff to send work to laboratories, the results of which are never received by the provider. Providers must develop and implement a system that tracks lab work from beginning to end.  That is, providers must be able to demonstrate through documentation that specimens were obtained and sent to the lab and that results were received in a timely manner and communicated to physicians. If the system of documentation indicates that results are overdue, practitioners have a legal duty to follow up with the lab and to obtain the results promptly. In other words, staff cannot get off the hook by saying that it is the responsibility of the lab to return results promptly!
When providers fail to meet these standards for documentation, dire consequences may result, including liability for negligence, loss of licensure and/or certification, and allegations of fraud and abuse.
©2020 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.


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