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Voice over needed for e-learning course
LTK6307131728X
This is an e-learning course for physicans. Approximately 40 minutes in length. We are looking for a narrator with an animated voice, who can also command authority. Preferrably male--but deeper female voice may be acceptable. This is the first in a series of courses for which we will be seeking voice talent. Please send us your quote too. Thanks
Jul 21, 2006 17:01:52 (GMT -05:00) Eastern Time (US & Canada)
Jul 24, 2006 00:00:00 (GMT -05:00) Eastern Time (US & Canada)
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0 direct invitation(s) have been sent by the voice seeker resulting in 0 audition(s) and/or proposal(s) so far.
Project Parameters
None
Flexible - USD 1000
Promos
English - North American
Not defined
Middle Age Female OR Middle Age Male
Not defined
There are no special pre-, post-, or production requirements for this project.
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No
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Script Details
Yes
The script is to be synced with a powerpoint presentation--which will be enhanced into a flash presentation. Attached is a sample of the script.
lide 1
AARISKMANAGEMENTDocumentation Workshop
Welcome to OUR COMPANY ’s Risk Management Documentation seminar. This seminar is part of OUR COMPANY ’s
Managing Risk program designed to help physicians implement effective risk management techniques
into their daily medical practice. This program is also one of the requirements for the OUR COMPANY Fellowship
Program.
Slide 2
Risk Rewards Program•1% premium discount for completing
this activity•To qualify, you must:
..Complete entire program
..Achieve 80% minimum passing score
..Not have completed this program in
2004 or 2005
By successfully completing this seminar you will receive a one percent discount on OUR COMPANY MUTUAL
premium. To receive the discount, you must achieve a minimum of 80% on the test at the end of this
program. To receive the discount for this program, you cannot have completed this program in 2004 or
2005.
Slide 3
Learning Objectives
•At the conclusion of this activity, participants
will be able to–Describe the principles of good medical record
documentation from a risk management
perspective.
–Analyze examples of medical record entries to
determine whether documentation is sufficient and
appropriate.
–Use the SOAP method of documentation to create
a medical record entry.
–Discuss the importance of good documentation
from a legal perspective.
At the conclusion of this activity, participants will be able to
describe the principles of good medical record documentation from a risk management perspective,
analyze examples of medical record entries to determine whether documentation is sufficient and
appropriate,
use the SOAP method of documentation to create a medical record entry, and
discuss the importance of good documentation from a legal perspective.
Slide 4
Purpose of complete and
accurate documentation
[Heading] Purpose of complete and accurate documentation
Slide 5
Purpose of documentation•Planning the patient’s care and treatment•Communicating with the healthcare team
•Peer review and quality assurance•Medical research
•Licensure certification of healthcare facility•Billing and third party reimbursement
•Defense of malpractice claims
There are multiple purposes to the medical record. First and foremost, the medical record is a vital
component in planning the patient’s medical care. Good documentation also facilitates communication
with other members of the healthcare team, such as consulting physicians, nurses, or physician assistants
who are also involved in the patient’s care.
The medical record is also used for peer review and quality assurance. It is essential to billing and
licensure of the health care facility. In medical research, such as at large teaching hospitals, it is vital
that documentation is complete. Most important, however, is that a complete and accurate medical
record is a crucial element of defending a physician in a malpractice lawsuit. Without an accurate
medical record it may prove difficult or even impossible to defend care, even when no malpractice
occurred.
Slide 6
Good documentation is the
best defense in the event of
a malpractice lawsuit.
It is important to remember that the physician and hospital will have the only accurate record of the care
and treatment provided. Patient recollections about dates and events, are often vague and exaggerated.
Thus, in the event of a medical malpractice lawsuit, the best way to defend your care is to show the jury
a complete and accurate record of your care. Documentation provides proof that you did the right
thing and can help demonstrate you are a careful and caring physician.
Slide 7
40%of all medical malpractice lawsuits areindefensiblebecause of problems with the
medical record.
Grand Rounds on Medical Malpractice, AMA
Medical liability experts estimate that up to 40% of all medical malpractice lawsuits are rendered
indefensible because of problems with the medical record.
Bad documentation can lead to settling a claim even when no malpractice has occurred.
Slide 8
When asked what areas of practice
made physicians feel vulnerable to a
malpractice suit:
•44% chart completeness and legibilityMedical Economics 12.17.04
When asked what areas of their practice made physicians feel vulnerable to a malpractice suit:
44% said chart completeness and legibility
Slide 9
What information is important
to document in the medical
record?
[Heading] What information is important to document in the medical record?
Slide 10
•Office visits•Hospital visits•Cancellations & no shows•Consultation notes•Covering physician notesDocument all clinical contacts
It is important to document all clinical contacts. This includes documenting
Office visits and hospital visits, as contemporaneously as possible. Documenting office visits too long
after the fact can lead to inaccuracies, errors and omissions.
Cancellations & no-show appointments can be a major source of liability. It is important that each
cancellation or no-show is brought to your attention and documented clearly.
Consultation notes should be comprehensive and accurate.
Finally, if one physician is covering for another, it is also very important to ensure that the covering
physician documents all contact with patients and all advice given.
Slide 11
Document all aspects of patient
care•History and physical•Vital signs•Current complaints•Diagnosis
..Goals and expected outcomes of treatment
..Patient response to treatment•Instructions for follow-up care•Medications
All aspects of patient care should be documented. This includes a
History and physical
Vital signs
Current complaints
Diagnosis
Goals and expected outcomes of treatment
Patient response to treatment
Instructions for follow-up care and medications
Slide 12
Document all aspects of patient
care
..Follow-up activity
..Informed consent process
..Noncompliance or informed refusal
..Requests for and release of medical
records
Other aspects of patient care that should be documented include:
Follow-up activity on previously discussed problems, recommendations, tests, etc.
While it is not possible to list all possible risks of a procedure, it is important the patient understands the
risks, benefits and alternatives of your treatment plan. Documentation of the informed consent process
can play an important role in defending a malpractice claim.
Patient noncompliance or informed refusal present major risks to the patient’s health and, without proper
documentation, can increase your exposure to professional liability.
Finally, all requests for and disclosure of medical records
Slide 13
Document all telephone calls
..Date & time
..Primary physician
..Name of patient & caller
..Purpose
..Advice or instructions
..Follow-up
Many physicians are surprised to learn that the ability to defend a medical malpractice claim can often
hinge on documentation of phone calls. For this reason, it is very important to document all clinically
relevant phone calls, including after-hours and weekend calls. Documentation should include
The date & time of the call
The patient’s primary physician
The name of patient & caller
The purpose of the call
The advice or instructions given
And all follow-up efforts by telephone
Slide 14
The use of preprinted phone message pads is a great way to capture important information when
documenting phone calls. OUR COMPANY offers phone message pads, at no charge, to its policyholders. To
request message pads, call OUR COMPANY ’s risk management division at 888*******.
Slide 15
..With other health care providers
..With patient/family
..Patient education and distribution of
materials
..Clinically relevant e-mailsDocument communications
It is also important to document relevant communication with the patient. This can include
communication
With other health care providers
With patient/family, especially follow-up instructions
Patient education and distribution of educational materials
And clinically relevant e-mails
Slide 16
How should the information be
recorded in the medical record?
[Heading] How should the information be recorded in the medical record?
Slide 17
Timeliness & Legibility
..Contemporaneous
..Progress notes dictated as soon
as possible
..Legible
Entries made contemporaneously with the service are more accurate and more
credible
Progress notes should be dictated as soon as possible after the encounter (within 24
hours).
And, of course, progress notes should be legible
Slide 18
Case Example: LegibilityA Texas physician was found negligent
in a patient’s death because of sloppy
handwriting on a prescription that was
filled incorrectly. Jury awarded the
plaintiff $450,000.
A Texas physician was found negligent in a patient’s death because of sloppy handwriting on a prescription that was filled incorrectly. The
jury awarded the plaintiff $450,000.
One of the lessons we can glean from this case is that a jury can often interpret illegible handwriting as an act of carelessness.
Slide 19
This prescription shows how slopping handwriting can and did lead to a serious medication error. The
physician in this case wrote a prescription for Isordil. Because the script was ambiguous, the pharmacist
dispensed Pledil.
Slide 20
Organize your medical charts
..A problem or diagnosis list
..An allergy list
..A medication list
..Patient’s name on every page
..Secure pages
..Progress notes in chronological order
The medical record should include
A problem or diagnosis list
Allergy list
Medication list with start and stop dates
The patient’s name should be on every page and all pages should be secured
Progress notes should be in chronological order
Slide 21
Organize your medical charts
..Organize by sections: progress
notes, labs, prescription refills,
letters, etc.
Organize by sections: progress notes, labs, prescription refills, letters, etc.
Establish a system to make sure every ordered test is completed and that the result is
reviewed by the ordering physician.
Slide 22
Subjective commentsObjective findingsAssessmentPlanCommon charting method:
SOAP
Physicians are encouraged to use a charting method that accurate records all the relevant information.
One example of this is the SOAP method.
The SOAP method involves capturing
The patient’s subjective description of their symptoms or condition.
Your objective clinical findings
Your assessment and interpretation of the subjective and objective information.
And your plan for current and future treatment.
Slide 23
Subjective vs. Objective
DocumentationSubjective dataNot supported by facts, open to
interpretationObjective dataFactual, leads to one conclusion
Let us take a moment to review what we mean when we refer to subjective data and objective data.
Subjective data is open to interpretation and is not supported by factual information. For example,
subjective comments include “I don’t feel good,” or “I have a temperature,” “I’ve put on a little weight.”
Objective data is factual and leads to only one conclusion. For example, objective data includes “temp
98” or “weight 196 lbs.”
Slide 24
Exercise:Subjective or ObjectiveSubjective •“I feel sick”
•B/P 120/80•Height 5 ft, weight 142 lbs
•“I have a terrible headache”
•Glucose level 220Objective
Subjective
Objective
Objective
In this exercise identify which of these statements are subjective and which are objective.
Slide 25
Documentation practices which
spell trouble
..Information gaps between entries
..Unsigned entries or transcriptions
..Unsigned lab or x-ray reports
..Signing records/orders without reading
them
..Missing pages
..Altering the medical record
It is important to be thorough and consistent in all your medical record entries. Inconsistencies can lead
to problems in the event of a medical malpractice suit, ruining your credibility and raising questions as
to the accuracy of your medical records. Try to avoid information gaps between entries. For example, if
a patient comes in for an office visit and you instruct the patient to call in a week to report how the new
medication is working, it is important to document that phone call, otherwise it could be assumed that
the patient never called and you never bothered to follow up with the patient. Any unsigned entries or
transcriptions imply that you never reviewed the office note for inaccuracies. Unsigned labs or x-ray
reports indicate that you never saw the results. It is important to sign and date all medical record entries,
labs or any reports before they go into the medical record. Some physicians may try to save time by
saving a pile of lab reports for the end of the day and then flipping through and signing them all at once.
This can become a liability if the physician doesn’t take the time to review each and every report. It is
important to inform office staff to never destroy or remove any pages from the medical record, and to
never send out pages of the original record, as missing pages can be damaging to your defense. Most
importantly, never alter a medical record once an entry has been made and signed. A plaintiff’s attorney
will immediately be able to identify alterations to the original record and this will make any defense in a
malpractice suit very difficult. An alteration of records can be grounds for cancellation of your
malpractice insurance.
Slide 26
Documentation practices which
spell trouble
..Finger pointing or “chart wars”
..Derogatory or discriminatory
remarks
..Arguments/conflicts with other
physicians, nursing staff or
administration
Criticism or finger pointing at the care or actions of other providers can lead to a medical malpractice
claim even if no malpractice occurred. These remarks are unimportant to patient care and should never
be documented in the medical record.
Derogatory or discriminatory remarks toward the patient or other providers in the medical record are
inappropriate, unnecessary and are problematic to your defense. If a patient is belligerent or
uncooperative, it is important to document this objectively and not include subjective remarks. For
example, it would be appropriate to document “patient verbally threatened staff” instead of writing
“patient is a jerk”.
Arguments or conflicts with other physicians, nurses or administration should never be documented in
the medical record.
Slide 27
ExerciseSample chart excerpt:
Patient is ignorant and disregarded my
medical instructions. She once again
did not complete the follow-up labs.
She is irresponsible and non-
compliant. The nurse failed to follow
up with the patient, and I have voiced
my concerns to the office manager
about the poor follow up in this office.
How should this office visit be documented?
Take a look at the following documentation for a patient who is noncompliant. As you read it, think
about what information is unrelated to patient care and how this could be better documented.
Patient is ignorant and disregarded my medical instructions. She once again did not complete the follow
up labs. She irresponsible and non-compliant. The nurse failed to follow up with the patient and I have
voiced my concerns to the office manager about the poor follow up in this office.
Slide 28
Revised excerpt:
Patient did not obtain labs I ordered at last
visit. I discussed with the patient the
importance of obtaining follow-up blood
work and the implications it has for her
medical condition. Patient understands.
She has agreed to obtain the blood work,
and will call the nurse once completed to
have the results faxed to the office.
Here is a suggested revision of the previous entry. Notice how this entry remains objective, yet still
documents the patient’s non-compliance.
Patient did not obtain labs I ordered at last visit. I discussed with the patient the importance of obtaining
follow up blood work and the implications it has for her medical condition. Patient understands. She has
agreed to obtain the blood work, and will call the nurse once completed to have the results faxed to the
office.
Slide 29
Documenting medical mishapsshow that you:
•Promptly identified the complication•Responded appropriately and aggressively
treated the complication•Maintained appropriate follow-up until
resolved
Medical mishaps or medical errors happen; however, it does not necessarily mean that you will be
named in a medical malpractice lawsuit. Appropriate documentation of medical errors is critical. First,
document that you promptly identified the situation, that you responded appropriately and aggressively.
Finally, document all follow up until the complication has resolved. It is important to show that you
recognized the importance of the situation and worked with the patient and medical team to provide the
best possible care to the patient.
Slide 30
Documentation of medical
mishaps should NOTinclude:
•Matters with legal implications, but no value to
patient care (conclusions about liability issues)
•Risk prevention activity
–Completion of incident report–Notification to claims department–Consultation with attorney–Notification of hospital risk management
There are things that should not be documented in the patient’s chart after a medical mishap. This
includes matters with legal implications, that have no value to the patient’s care. Risk prevention
activities including completing incident reports, notifying the claims department, consulting with an
attorney or notifying ISMIE or hospital risk management. While these activities are important, they are
not applicable to patient care and should be kept out of the medical record.
Slide 31
Documentation of medical
mishaps should NOTinclude:
..Placing blame on yourself
..Terms that misrepresent,
exaggerate or understate
objective facts
..Red Flagterms like mistake, or
error
When documenting after a medical mishap, be sure not to place blame on yourself for the mishap.
Immediately after an adverse event, it may be uncertain what factors contributed to the event and it
would be presumptuous to assume responsibility. Do not misrepresent, exaggerate or understate
objective facts. You may be inclined to downplay an adverse event, however, you need to document
accurately or it may appear an attempt to place blame or cover up your role. Words like mistake or error
are red flags to plaintiff’s attorneys. Avoid using these words and simply and objectively state the
medical care that was provided.
Slide 32
Sample chart excerpt:
Patient returned for yearly physical.
Mammogram from one year ago was
read as abnormal and required follow
up. Radiology department never notified
this office of abnormal results. The
nurse failed to report abnormal results
to the patient. Told patient may have
cancer and if she does she stated she
will sue.
How should this office visit be documented?
Look at the sample chart excerpt regarding a missed abnormal mammogram.
Patient returned for yearly physical. Mammogram from one year ago was read as abnormal and required
follow up. Radiology department never notified this office of abnormal results. The nurse failed to
report abnormal results to the patient. Told patient she may have cancer and if she does she stated she
will sue.
Think about how this scenario can be documented more objectively and in a less inflammatory way.
[Pause 5 sec]
Slide 33
Revised excerpt:
Patient returns for yearly physical.
Mammogram from one year ago was
abnormal. Had long conversation with
patient regarding the meaning of test
results. Reviewed nature of breast cancer
and patient given appropriate educational
materials. Scheduled radiology
appointment, biopsy and follow-up
appointment.
Here is one suggestion for revising this excerpt without implicating the radiology department and the
nurse, and by showing the physician made the appropriate steps in insuring the patient received follow
up care.
Patient returns for yearly physical. Mammogram from one year ago was abnormal. Had long
conversation with patient regarding the meaning of the test results. Reviewed nature of breast cancer and
patient given appropriate educational materials. Scheduled radiology appointment, biopsy and follow up
appointment.
Slide 34
Correcting errors in
documentation•Correct promptly: soon after the treatment
provided.
•Don’t obliterate entries. Draw a single line
through the error.
•Date and initial correction.
•Never squeeze corrections between lines
or in the margins of the medical record.
If an error is made in documentation, it is important to correct appropriately so it does not appear that an
alteration has been made to the record. The correction should be made as soon as the error is identified.
For example, it would be inappropriate to try to make changes to a record from one year prior. Don’t
obliterate entries. Draw a single line through the error so that the text is still legible. Date and initial the
correction. Make sure the correction is legible, squeezing between lines or in the margins of the medical
record may make it difficult to read.
Slide 35
Here are examples of improper and proper ways for correcting charting errors. In the upper left, the
correction is written over the original text and it is difficult to read. On the upper right, the proper
method is used. The correction is legible and the initials and date are next to the correction.
The in the second example, the previous documentation is completely obliterated. Below, a single line is
drawn through the word and the initials and date are next to the correction.
Slide 36
Correcting errors in
documentation•Do notmake corrections after a complication
has occurred (self-serving comments will be
damaging to defense).
•Do notmake corrections after a lawsuit is filed
(remember the attorney already has a copy of
the record).
•Do notmake corrections after a copy of the
medical record has been released.
•Do notremove or destroy any pages or forms
from the record.
Again, timing of corrections is important. Do not make corrections after a complication has occurred.
These corrections may appear self serving and could be damaging to the defense. Do not make
corrections after a lawsuit has been filed. Most likely the plaintiff’s attorney already has a copy of the
record. Do not make corrections after a copy of the medical records has been released. Two different
copies of a record will make a defense difficult. Finally, do not remove or destroy and pages or forms
from the medical record.
Slide 37
Adding an addendumIf an addendum is required, head the note:
“(Current Date) addendum to the note(Previous Date)”
then add the information to be documented
There is a correct way to clarify information in the medical record without appearing as though you are
deleting or altering facts. This can be accomplished through the use of an addendum. The use of an
addendum is reasonable and appropriate as long as it is designated as such and signed and dated.
Addenda are used to clarify facts that are important to patient care and should not be used to falsify or
change the record, or to add information that may appear defensive.
Slide 38
Take a look at this sample medical record. What errors in documentation do you notice? [Pause 10 sec]
Slide 39
Notice how the numbering is out of order which can cause confusion, words are squeezed into the
margin or between lines, some words have been scribbled out and finally overall the note is illegible in
places due to sloppy handwriting. Your progress notes should be clear and legible, so that any other
care provider can look at the note and understand your thought process.
Slide 40
..Use only hospital approved abbreviations in your
hospital medical records.
..If you use your own abbreviations in your office
medical records, make sure there is a master list
available for deciphering them.
..Don’t use abbreviations that may be seen as
derogatory:
..SOBShortness of breath
..LOBNH Lights on but nobody home
..FLKFunny looking kidAbbreviations
Abbreviations are common in medical records. They save time and space and most medical staff can
quickly identify the meaning. However abbreviations can also cause confusion if not understood by all
who have access to the medical record. It is important to use only hospital approved abbreviations in
your hospital medical records. Most hospitals keep a list of approved abbreviations. If you use your own
abbreviations in your office, keep a master list. This will be helpful to new staff and to aid in your
defense if you ever need to explain the contents of your records to an attorney. Finally, don’t use
abbreviations that may be seen as derogatory.
Slide 41
Who is allowed to receive copies
of the medical record?
Questions regarding the release of medical records are common among physicians and their office staff.
Concerns about maintaining patient confidentiality rise when requests for copies of the medical record
are made. We will now discuss some basic guidelines for releasing medical records. For more
information, you can call the risk management department at ISMIE and request the Physician’s Guide
to Medical Record Access and Retention.
Slide 42
..Adult patient
..Legal guardian
..Parent of minor
..Minor who is married, pregnant or a parent
..Administrator/executor of decedent’s estate
..An attorney-in-fact, power of attorney for health
care, or health care surrogateWho can authorize release of
medical records:
Authorization for release of medical records is required before copies can be sent to a third party.
Authorization can be obtained by an adult patient, a legal guardian, the parent of a minor patient, a
minor patient who is emancipated meaning that they are married, pregnant or a parent.
The administrator or executor of decedent’s estate, an attorney in fact, power of attorney for healthcare
or a health care surrogate.
Slide 43
Release of medical information
..Neverrelease the original record.
..Develop and implement policy and
procedures for record release.
..Require proper authorization!
When releasing copies of the medical record, never release the original record. The office should
establish written policy regarding how to handle record releases. Instructions and forms for proper
authorization should be included in the policy.
Slide 44
A request for medical records:
..Must be honored within 30 days of
receipt of request.
..If a copy cannot be provided within 30
days, a written explanation must be
given to the requestor and the practice
may have a single 30 day extension.
..Ultimately, the medical records must
be provided within 60 days of a
request.
An authorized request for medical records must be honored within 30 days of receipt of the request. If a
copy can not be provided within 30 days, the physician must inform the requester in writing and provide
a reason for the delay. The practice then has an additional 30 days to comply with the request.
Ultimately the request must be honored within 60 days.
Slide 45
Withholding medical records•A physician may charge a fee for the
copying of medical records, but the
physician may not withhold the medical
record if the patient does not pay for the
copying fee.
•A physician may notwithhold medical
records because a patient fails to pay
for services.
Physicians can charge a fee for the copying of medical records. However, if the patient does not pay the
fee, the physician can not withhold the record. This rule also applies to medical bills. The physician may
not withhold medical records because a patient fails to pay for services.
Slide 46
Copy fee legislation*
..Hospitals and physicians are limited to a
$22.28 maximum handling charge plus:
..$0.84 per page for the first 25 pages
..$0.56 for pages 26-50 pages
..$0.28 for each page in excess of 50 pages
..Copies made from microfiche or microfilm
can’t exceed $1.39 per page
..Actual postage*Illinois Comptroller’s Office, 2006
There are guidelines for how much a physician office can charge for making copies. Copy fee legislation
is set forth each year by the Comptroller’s office.
Slide 47
Copy fee under HIPAAApplies when the records are being given to the
patient or health care power of attorney.
Cost is a reasonable cost-based fee which
includes:
..Copying (supplies, labor)
..Postage
..Preparing of explanation or summary
Patient is charged the lesser of the two fees.
HIPAA also outlines a copy fee. Once the fee has been calculated under both Illinois law and HIPAA
law, the patient is to be charged the lesser of the two fees.
Slide 48
Record release exceptions
Authorization is not required for:
..Continuity of care
..Referring physician
..Physician’s professional liability
carrier
..Physician’s defense counsel
There are exceptions to the requirement for authorization prior to release of the medical record. First, for
reasons of continuity of care in which the patient is involved in ongoing health care treatment with other
physicians including a referring physician. Authorization is not required by the physician’s professional
liability carrier or the physician’s defense counsel.
Slide 49
Record release exceptions
Authorization is not required for:
..Coroner’s inquiries
..Request by a peer review organization under
contract by the federal government or other
governmental agencies
..Workers’Compensation cases
..Communicable disease reporting
..Sexually transmitted disease reporting
..Child, elder or disabled adult abuse reporting
Other exceptions include coroner inquiries, requests from a peer review organization under contract by
the federal government, or other government agencies. For cases involving worker’s compensation, a
physician is required by law to provide copies of medical records to the patient, a patient’s employer or
employer’s worker’s compensation insurance company. Mandated reports of communicable diseases,
conditions, or injuries does not require authorization, nor does child, elder or disabled adult abuse
reporting.
Slide 50
Protected Information
Federal law prohibits disclosure of
information related to the following:
•Mental health treatment
•Drug/alcohol abuse treatment•HIV/AIDS informationSpecific consent is required to release this
information.
Certain medical information is protected under federal law and requires specific consent for release of
that information. This includes information related to mental health treatment, alcohol or drug treatment,
and HIV/AIDS records. Physicians should have patients sign a separate and specific request form for the
release of this information. If a request is made for a copy of the record, and the patient has not given a
specific consent for this information, that information should be excluded from the copy that is sent to
the requestor.
Slide 51
As a general guideline retain records 10
years from last patient encounter.
Record retention guidelinesChildhood immunization Permanently
Legal disability Permanently
Records in malpractice claimPermanently
Physicians and office managers often wonder how long to keep a patient’s medical record. As a general
guideline, ISMIE recommends that physicians retain records for 10 years from the last patient encounter.
This 10 year rule is based on the requirements of the Hospital Licensing Act. There are a few
exceptions: childhood immunization records, patients with a legal disability and records involved in a
medical malpractice claims should be kept permanently.
Slide 52
Consider an Electronic Medical
Record (EMR)
Advantages over paper-based systems:
..Reduces paperwork
..Prompt and convenient record retrieval
..Provide prompts for specific findings, reminders
about preventive testing
..Warnings about contraindications and drug
interactions
..Tie to practice management systems to minimize
allegations of fraud and abuse attributable to
billing
More physicians are turning to the electronic medical record as a means for documenting patient care.
There are many advantages to an electronic medical record system, in that it reduces paper work, and
provides prompt and convenient record retrieval. Most systems can flag specific findings and reminders
about preventive testing. Warning alarms can alert the physician to contraindications and drug
interactions reducing the likelihood of a medication error. Some systems can integrate with practice
management systems to assimilate billing and medical record systems.
Slide 53
Advantages over paper-based
systems (cont’d)
..Accessible to physicians on call or away from the
office
..Permits simultaneous access by multiple users
..Interfaces with PDAs for functions of patient
tracking, prescribing, drug interactions, test results,
billing and coding
With an EMR, physicians can have access to a patient’s medical record from remote locations and
multiple healthcare providers can be looking at the patient’s record at the same time. Some EMRs
interface with PDAs for patient tracking, prescribing, drug interactions, test results and billing and
coding.
AARISKMANAGEMENTDocumentation Workshop
Welcome to OUR Risk Management Documentation seminar. This seminar is part of OUR COMPANY
Managing Risk program designed to help physicians implement effective risk management techniques
into their daily medical practice. This program is also one of the requirements for the OUR COMPANY Fellowship
Program.
Slide 2
Risk Rewards Program•1% premium discount for completing
this activity•To qualify, you must:
..Complete entire program
..Achieve 80% minimum passing score
..Not have completed this program in
2004 or 2005
By successfully completing this seminar you will receive a one percent discount on your OUR COMPANY Mutual
premium. To receive the discount, you must achieve a minimum of 80% on the test at the end of this
program. To receive the discount for this program, you cannot have completed this program in 2004 or
2005.
.............
..............................
lide 1
AARISKMANAGEMENTDocumentation Workshop
Welcome to OUR COMPANY ’s Risk Management Documentation seminar. This seminar is part of OUR COMPANY ’s
Managing Risk program designed to help physicians implement effective risk management techniques
into their daily medical practice. This program is also one of the requirements for the OUR COMPANY Fellowship
Program.
Slide 2
Risk Rewards Program•1% premium discount for completing
this activity•To qualify, you must:
..Complete entire program
..Achieve 80% minimum passing score
..Not have completed this program in
2004 or 2005
By successfully completing this seminar you will receive a one percent discount on OUR COMPANY MUTUAL
premium. To receive the discount, you must achieve a minimum of 80% on the test at the end of this
program. To receive the discount for this program, you cannot have completed this program in 2004 or
2005.
Slide 3
Learning Objectives
•At the conclusion of this activity, participants
will be able to–Describe the principles of good medical record
documentation from a risk management
perspective.
–Analyze examples of medical record entries to
determine whether documentation is sufficient and
appropriate.
–Use the SOAP method of documentation to create
a medical record entry.
–Discuss the importance of good documentation
from a legal perspective.
At the conclusion of this activity, participants will be able to
describe the principles of good medical record documentation from a risk management perspective,
analyze examples of medical record entries to determine whether documentation is sufficient and
appropriate,
use the SOAP method of documentation to create a medical record entry, and
discuss the importance of good documentation from a legal perspective.
Slide 4
Purpose of complete and
accurate documentation
[Heading] Purpose of complete and accurate documentation
Slide 5
Purpose of documentation•Planning the patient’s care and treatment•Communicating with the healthcare team
•Peer review and quality assurance•Medical research
•Licensure certification of healthcare facility•Billing and third party reimbursement
•Defense of malpractice claims
There are multiple purposes to the medical record. First and foremost, the medical record is a vital
component in planning the patient’s medical care. Good documentation also facilitates communication
with other members of the healthcare team, such as consulting physicians, nurses, or physician assistants
who are also involved in the patient’s care.
The medical record is also used for peer review and quality assurance. It is essential to billing and
licensure of the health care facility. In medical research, such as at large teaching hospitals, it is vital
that documentation is complete. Most important, however, is that a complete and accurate medical
record is a crucial element of defending a physician in a malpractice lawsuit. Without an accurate
medical record it may prove difficult or even impossible to defend care, even when no malpractice
occurred.
Slide 6
Good documentation is the
best defense in the event of
a malpractice lawsuit.
It is important to remember that the physician and hospital will have the only accurate record of the care
and treatment provided. Patient recollections about dates and events, are often vague and exaggerated.
Thus, in the event of a medical malpractice lawsuit, the best way to defend your care is to show the jury
a complete and accurate record of your care. Documentation provides proof that you did the right
thing and can help demonstrate you are a careful and caring physician.
Slide 7
40%of all medical malpractice lawsuits areindefensiblebecause of problems with the
medical record.
Grand Rounds on Medical Malpractice, AMA
Medical liability experts estimate that up to 40% of all medical malpractice lawsuits are rendered
indefensible because of problems with the medical record.
Bad documentation can lead to settling a claim even when no malpractice has occurred.
Slide 8
When asked what areas of practice
made physicians feel vulnerable to a
malpractice suit:
•44% chart completeness and legibilityMedical Economics 12.17.04
When asked what areas of their practice made physicians feel vulnerable to a malpractice suit:
44% said chart completeness and legibility
Slide 9
What information is important
to document in the medical
record?
[Heading] What information is important to document in the medical record?
Slide 10
•Office visits•Hospital visits•Cancellations & no shows•Consultation notes•Covering physician notesDocument all clinical contacts
It is important to document all clinical contacts. This includes documenting
Office visits and hospital visits, as contemporaneously as possible. Documenting office visits too long
after the fact can lead to inaccuracies, errors and omissions.
Cancellations & no-show appointments can be a major source of liability. It is important that each
cancellation or no-show is brought to your attention and documented clearly.
Consultation notes should be comprehensive and accurate.
Finally, if one physician is covering for another, it is also very important to ensure that the covering
physician documents all contact with patients and all advice given.
Slide 11
Document all aspects of patient
care•History and physical•Vital signs•Current complaints•Diagnosis
..Goals and expected outcomes of treatment
..Patient response to treatment•Instructions for follow-up care•Medications
All aspects of patient care should be documented. This includes a
History and physical
Vital signs
Current complaints
Diagnosis
Goals and expected outcomes of treatment
Patient response to treatment
Instructions for follow-up care and medications
Slide 12
Document all aspects of patient
care
..Follow-up activity
..Informed consent process
..Noncompliance or informed refusal
..Requests for and release of medical
records
Other aspects of patient care that should be documented include:
Follow-up activity on previously discussed problems, recommendations, tests, etc.
While it is not possible to list all possible risks of a procedure, it is important the patient understands the
risks, benefits and alternatives of your treatment plan. Documentation of the informed consent process
can play an important role in defending a malpractice claim.
Patient noncompliance or informed refusal present major risks to the patient’s health and, without proper
documentation, can increase your exposure to professional liability.
Finally, all requests for and disclosure of medical records
Slide 13
Document all telephone calls
..Date & time
..Primary physician
..Name of patient & caller
..Purpose
..Advice or instructions
..Follow-up
Many physicians are surprised to learn that the ability to defend a medical malpractice claim can often
hinge on documentation of phone calls. For this reason, it is very important to document all clinically
relevant phone calls, including after-hours and weekend calls. Documentation should include
The date & time of the call
The patient’s primary physician
The name of patient & caller
The purpose of the call
The advice or instructions given
And all follow-up efforts by telephone
Slide 14
The use of preprinted phone message pads is a great way to capture important information when
documenting phone calls. OUR COMPANY offers phone message pads, at no charge, to its policyholders. To
request message pads, call OUR COMPANY ’s risk management division at 888*******.
Slide 15
..With other health care providers
..With patient/family
..Patient education and distribution of
materials
..Clinically relevant e-mailsDocument communications
It is also important to document relevant communication with the patient. This can include
communication
With other health care providers
With patient/family, especially follow-up instructions
Patient education and distribution of educational materials
And clinically relevant e-mails
Slide 16
How should the information be
recorded in the medical record?
[Heading] How should the information be recorded in the medical record?
Slide 17
Timeliness & Legibility
..Contemporaneous
..Progress notes dictated as soon
as possible
..Legible
Entries made contemporaneously with the service are more accurate and more
credible
Progress notes should be dictated as soon as possible after the encounter (within 24
hours).
And, of course, progress notes should be legible
Slide 18
Case Example: LegibilityA Texas physician was found negligent
in a patient’s death because of sloppy
handwriting on a prescription that was
filled incorrectly. Jury awarded the
plaintiff $450,000.
A Texas physician was found negligent in a patient’s death because of sloppy handwriting on a prescription that was filled incorrectly. The
jury awarded the plaintiff $450,000.
One of the lessons we can glean from this case is that a jury can often interpret illegible handwriting as an act of carelessness.
Slide 19
This prescription shows how slopping handwriting can and did lead to a serious medication error. The
physician in this case wrote a prescription for Isordil. Because the script was ambiguous, the pharmacist
dispensed Pledil.
Slide 20
Organize your medical charts
..A problem or diagnosis list
..An allergy list
..A medication list
..Patient’s name on every page
..Secure pages
..Progress notes in chronological order
The medical record should include
A problem or diagnosis list
Allergy list
Medication list with start and stop dates
The patient’s name should be on every page and all pages should be secured
Progress notes should be in chronological order
Slide 21
Organize your medical charts
..Organize by sections: progress
notes, labs, prescription refills,
letters, etc.
Organize by sections: progress notes, labs, prescription refills, letters, etc.
Establish a system to make sure every ordered test is completed and that the result is
reviewed by the ordering physician.
Slide 22
Subjective commentsObjective findingsAssessmentPlanCommon charting method:
SOAP
Physicians are encouraged to use a charting method that accurate records all the relevant information.
One example of this is the SOAP method.
The SOAP method involves capturing
The patient’s subjective description of their symptoms or condition.
Your objective clinical findings
Your assessment and interpretation of the subjective and objective information.
And your plan for current and future treatment.
Slide 23
Subjective vs. Objective
DocumentationSubjective dataNot supported by facts, open to
interpretationObjective dataFactual, leads to one conclusion
Let us take a moment to review what we mean when we refer to subjective data and objective data.
Subjective data is open to interpretation and is not supported by factual information. For example,
subjective comments include “I don’t feel good,” or “I have a temperature,” “I’ve put on a little weight.”
Objective data is factual and leads to only one conclusion. For example, objective data includes “temp
98” or “weight 196 lbs.”
Slide 24
Exercise:Subjective or ObjectiveSubjective •“I feel sick”
•B/P 120/80•Height 5 ft, weight 142 lbs
•“I have a terrible headache”
•Glucose level 220Objective
Subjective
Objective
Objective
In this exercise identify which of these statements are subjective and which are objective.
Slide 25
Documentation practices which
spell trouble
..Information gaps between entries
..Unsigned entries or transcriptions
..Unsigned lab or x-ray reports
..Signing records/orders without reading
them
..Missing pages
..Altering the medical record
It is important to be thorough and consistent in all your medical record entries. Inconsistencies can lead
to problems in the event of a medical malpractice suit, ruining your credibility and raising questions as
to the accuracy of your medical records. Try to avoid information gaps between entries. For example, if
a patient comes in for an office visit and you instruct the patient to call in a week to report how the new
medication is working, it is important to document that phone call, otherwise it could be assumed that
the patient never called and you never bothered to follow up with the patient. Any unsigned entries or
transcriptions imply that you never reviewed the office note for inaccuracies. Unsigned labs or x-ray
reports indicate that you never saw the results. It is important to sign and date all medical record entries,
labs or any reports before they go into the medical record. Some physicians may try to save time by
saving a pile of lab reports for the end of the day and then flipping through and signing them all at once.
This can become a liability if the physician doesn’t take the time to review each and every report. It is
important to inform office staff to never destroy or remove any pages from the medical record, and to
never send out pages of the original record, as missing pages can be damaging to your defense. Most
importantly, never alter a medical record once an entry has been made and signed. A plaintiff’s attorney
will immediately be able to identify alterations to the original record and this will make any defense in a
malpractice suit very difficult. An alteration of records can be grounds for cancellation of your
malpractice insurance.
Slide 26
Documentation practices which
spell trouble
..Finger pointing or “chart wars”
..Derogatory or discriminatory
remarks
..Arguments/conflicts with other
physicians, nursing staff or
administration
Criticism or finger pointing at the care or actions of other providers can lead to a medical malpractice
claim even if no malpractice occurred. These remarks are unimportant to patient care and should never
be documented in the medical record.
Derogatory or discriminatory remarks toward the patient or other providers in the medical record are
inappropriate, unnecessary and are problematic to your defense. If a patient is belligerent or
uncooperative, it is important to document this objectively and not include subjective remarks. For
example, it would be appropriate to document “patient verbally threatened staff” instead of writing
“patient is a jerk”.
Arguments or conflicts with other physicians, nurses or administration should never be documented in
the medical record.
Slide 27
ExerciseSample chart excerpt:
Patient is ignorant and disregarded my
medical instructions. She once again
did not complete the follow-up labs.
She is irresponsible and non-
compliant. The nurse failed to follow
up with the patient, and I have voiced
my concerns to the office manager
about the poor follow up in this office.
How should this office visit be documented?
Take a look at the following documentation for a patient who is noncompliant. As you read it, think
about what information is unrelated to patient care and how this could be better documented.
Patient is ignorant and disregarded my medical instructions. She once again did not complete the follow
up labs. She irresponsible and non-compliant. The nurse failed to follow up with the patient and I have
voiced my concerns to the office manager about the poor follow up in this office.
Slide 28
Revised excerpt:
Patient did not obtain labs I ordered at last
visit. I discussed with the patient the
importance of obtaining follow-up blood
work and the implications it has for her
medical condition. Patient understands.
She has agreed to obtain the blood work,
and will call the nurse once completed to
have the results faxed to the office.
Here is a suggested revision of the previous entry. Notice how this entry remains objective, yet still
documents the patient’s non-compliance.
Patient did not obtain labs I ordered at last visit. I discussed with the patient the importance of obtaining
follow up blood work and the implications it has for her medical condition. Patient understands. She has
agreed to obtain the blood work, and will call the nurse once completed to have the results faxed to the
office.
Slide 29
Documenting medical mishapsshow that you:
•Promptly identified the complication•Responded appropriately and aggressively
treated the complication•Maintained appropriate follow-up until
resolved
Medical mishaps or medical errors happen; however, it does not necessarily mean that you will be
named in a medical malpractice lawsuit. Appropriate documentation of medical errors is critical. First,
document that you promptly identified the situation, that you responded appropriately and aggressively.
Finally, document all follow up until the complication has resolved. It is important to show that you
recognized the importance of the situation and worked with the patient and medical team to provide the
best possible care to the patient.
Slide 30
Documentation of medical
mishaps should NOTinclude:
•Matters with legal implications, but no value to
patient care (conclusions about liability issues)
•Risk prevention activity
–Completion of incident report–Notification to claims department–Consultation with attorney–Notification of hospital risk management
There are things that should not be documented in the patient’s chart after a medical mishap. This
includes matters with legal implications, that have no value to the patient’s care. Risk prevention
activities including completing incident reports, notifying the claims department, consulting with an
attorney or notifying ISMIE or hospital risk management. While these activities are important, they are
not applicable to patient care and should be kept out of the medical record.
Slide 31
Documentation of medical
mishaps should NOTinclude:
..Placing blame on yourself
..Terms that misrepresent,
exaggerate or understate
objective facts
..Red Flagterms like mistake, or
error
When documenting after a medical mishap, be sure not to place blame on yourself for the mishap.
Immediately after an adverse event, it may be uncertain what factors contributed to the event and it
would be presumptuous to assume responsibility. Do not misrepresent, exaggerate or understate
objective facts. You may be inclined to downplay an adverse event, however, you need to document
accurately or it may appear an attempt to place blame or cover up your role. Words like mistake or error
are red flags to plaintiff’s attorneys. Avoid using these words and simply and objectively state the
medical care that was provided.
Slide 32
Sample chart excerpt:
Patient returned for yearly physical.
Mammogram from one year ago was
read as abnormal and required follow
up. Radiology department never notified
this office of abnormal results. The
nurse failed to report abnormal results
to the patient. Told patient may have
cancer and if she does she stated she
will sue.
How should this office visit be documented?
Look at the sample chart excerpt regarding a missed abnormal mammogram.
Patient returned for yearly physical. Mammogram from one year ago was read as abnormal and required
follow up. Radiology department never notified this office of abnormal results. The nurse failed to
report abnormal results to the patient. Told patient she may have cancer and if she does she stated she
will sue.
Think about how this scenario can be documented more objectively and in a less inflammatory way.
[Pause 5 sec]
Slide 33
Revised excerpt:
Patient returns for yearly physical.
Mammogram from one year ago was
abnormal. Had long conversation with
patient regarding the meaning of test
results. Reviewed nature of breast cancer
and patient given appropriate educational
materials. Scheduled radiology
appointment, biopsy and follow-up
appointment.
Here is one suggestion for revising this excerpt without implicating the radiology department and the
nurse, and by showing the physician made the appropriate steps in insuring the patient received follow
up care.
Patient returns for yearly physical. Mammogram from one year ago was abnormal. Had long
conversation with patient regarding the meaning of the test results. Reviewed nature of breast cancer and
patient given appropriate educational materials. Scheduled radiology appointment, biopsy and follow up
appointment.
Slide 34
Correcting errors in
documentation•Correct promptly: soon after the treatment
provided.
•Don’t obliterate entries. Draw a single line
through the error.
•Date and initial correction.
•Never squeeze corrections between lines
or in the margins of the medical record.
If an error is made in documentation, it is important to correct appropriately so it does not appear that an
alteration has been made to the record. The correction should be made as soon as the error is identified.
For example, it would be inappropriate to try to make changes to a record from one year prior. Don’t
obliterate entries. Draw a single line through the error so that the text is still legible. Date and initial the
correction. Make sure the correction is legible, squeezing between lines or in the margins of the medical
record may make it difficult to read.
Slide 35
Here are examples of improper and proper ways for correcting charting errors. In the upper left, the
correction is written over the original text and it is difficult to read. On the upper right, the proper
method is used. The correction is legible and the initials and date are next to the correction.
The in the second example, the previous documentation is completely obliterated. Below, a single line is
drawn through the word and the initials and date are next to the correction.
Slide 36
Correcting errors in
documentation•Do notmake corrections after a complication
has occurred (self-serving comments will be
damaging to defense).
•Do notmake corrections after a lawsuit is filed
(remember the attorney already has a copy of
the record).
•Do notmake corrections after a copy of the
medical record has been released.
•Do notremove or destroy any pages or forms
from the record.
Again, timing of corrections is important. Do not make corrections after a complication has occurred.
These corrections may appear self serving and could be damaging to the defense. Do not make
corrections after a lawsuit has been filed. Most likely the plaintiff’s attorney already has a copy of the
record. Do not make corrections after a copy of the medical records has been released. Two different
copies of a record will make a defense difficult. Finally, do not remove or destroy and pages or forms
from the medical record.
Slide 37
Adding an addendumIf an addendum is required, head the note:
“(Current Date) addendum to the note(Previous Date)”
then add the information to be documented
There is a correct way to clarify information in the medical record without appearing as though you are
deleting or altering facts. This can be accomplished through the use of an addendum. The use of an
addendum is reasonable and appropriate as long as it is designated as such and signed and dated.
Addenda are used to clarify facts that are important to patient care and should not be used to falsify or
change the record, or to add information that may appear defensive.
Slide 38
Take a look at this sample medical record. What errors in documentation do you notice? [Pause 10 sec]
Slide 39
Notice how the numbering is out of order which can cause confusion, words are squeezed into the
margin or between lines, some words have been scribbled out and finally overall the note is illegible in
places due to sloppy handwriting. Your progress notes should be clear and legible, so that any other
care provider can look at the note and understand your thought process.
Slide 40
..Use only hospital approved abbreviations in your
hospital medical records.
..If you use your own abbreviations in your office
medical records, make sure there is a master list
available for deciphering them.
..Don’t use abbreviations that may be seen as
derogatory:
..SOBShortness of breath
..LOBNH Lights on but nobody home
..FLKFunny looking kidAbbreviations
Abbreviations are common in medical records. They save time and space and most medical staff can
quickly identify the meaning. However abbreviations can also cause confusion if not understood by all
who have access to the medical record. It is important to use only hospital approved abbreviations in
your hospital medical records. Most hospitals keep a list of approved abbreviations. If you use your own
abbreviations in your office, keep a master list. This will be helpful to new staff and to aid in your
defense if you ever need to explain the contents of your records to an attorney. Finally, don’t use
abbreviations that may be seen as derogatory.
Slide 41
Who is allowed to receive copies
of the medical record?
Questions regarding the release of medical records are common among physicians and their office staff.
Concerns about maintaining patient confidentiality rise when requests for copies of the medical record
are made. We will now discuss some basic guidelines for releasing medical records. For more
information, you can call the risk management department at ISMIE and request the Physician’s Guide
to Medical Record Access and Retention.
Slide 42
..Adult patient
..Legal guardian
..Parent of minor
..Minor who is married, pregnant or a parent
..Administrator/executor of decedent’s estate
..An attorney-in-fact, power of attorney for health
care, or health care surrogateWho can authorize release of
medical records:
Authorization for release of medical records is required before copies can be sent to a third party.
Authorization can be obtained by an adult patient, a legal guardian, the parent of a minor patient, a
minor patient who is emancipated meaning that they are married, pregnant or a parent.
The administrator or executor of decedent’s estate, an attorney in fact, power of attorney for healthcare
or a health care surrogate.
Slide 43
Release of medical information
..Neverrelease the original record.
..Develop and implement policy and
procedures for record release.
..Require proper authorization!
When releasing copies of the medical record, never release the original record. The office should
establish written policy regarding how to handle record releases. Instructions and forms for proper
authorization should be included in the policy.
Slide 44
A request for medical records:
..Must be honored within 30 days of
receipt of request.
..If a copy cannot be provided within 30
days, a written explanation must be
given to the requestor and the practice
may have a single 30 day extension.
..Ultimately, the medical records must
be provided within 60 days of a
request.
An authorized request for medical records must be honored within 30 days of receipt of the request. If a
copy can not be provided within 30 days, the physician must inform the requester in writing and provide
a reason for the delay. The practice then has an additional 30 days to comply with the request.
Ultimately the request must be honored within 60 days.
Slide 45
Withholding medical records•A physician may charge a fee for the
copying of medical records, but the
physician may not withhold the medical
record if the patient does not pay for the
copying fee.
•A physician may notwithhold medical
records because a patient fails to pay
for services.
Physicians can charge a fee for the copying of medical records. However, if the patient does not pay the
fee, the physician can not withhold the record. This rule also applies to medical bills. The physician may
not withhold medical records because a patient fails to pay for services.
Slide 46
Copy fee legislation*
..Hospitals and physicians are limited to a
$22.28 maximum handling charge plus:
..$0.84 per page for the first 25 pages
..$0.56 for pages 26-50 pages
..$0.28 for each page in excess of 50 pages
..Copies made from microfiche or microfilm
can’t exceed $1.39 per page
..Actual postage*Illinois Comptroller’s Office, 2006
There are guidelines for how much a physician office can charge for making copies. Copy fee legislation
is set forth each year by the Comptroller’s office.
Slide 47
Copy fee under HIPAAApplies when the records are being given to the
patient or health care power of attorney.
Cost is a reasonable cost-based fee which
includes:
..Copying (supplies, labor)
..Postage
..Preparing of explanation or summary
Patient is charged the lesser of the two fees.
HIPAA also outlines a copy fee. Once the fee has been calculated under both Illinois law and HIPAA
law, the patient is to be charged the lesser of the two fees.
Slide 48
Record release exceptions
Authorization is not required for:
..Continuity of care
..Referring physician
..Physician’s professional liability
carrier
..Physician’s defense counsel
There are exceptions to the requirement for authorization prior to release of the medical record. First, for
reasons of continuity of care in which the patient is involved in ongoing health care treatment with other
physicians including a referring physician. Authorization is not required by the physician’s professional
liability carrier or the physician’s defense counsel.
Slide 49
Record release exceptions
Authorization is not required for:
..Coroner’s inquiries
..Request by a peer review organization under
contract by the federal government or other
governmental agencies
..Workers’Compensation cases
..Communicable disease reporting
..Sexually transmitted disease reporting
..Child, elder or disabled adult abuse reporting
Other exceptions include coroner inquiries, requests from a peer review organization under contract by
the federal government, or other government agencies. For cases involving worker’s compensation, a
physician is required by law to provide copies of medical records to the patient, a patient’s employer or
employer’s worker’s compensation insurance company. Mandated reports of communicable diseases,
conditions, or injuries does not require authorization, nor does child, elder or disabled adult abuse
reporting.
Slide 50
Protected Information
Federal law prohibits disclosure of
information related to the following:
•Mental health treatment
•Drug/alcohol abuse treatment•HIV/AIDS informationSpecific consent is required to release this
information.
Certain medical information is protected under federal law and requires specific consent for release of
that information. This includes information related to mental health treatment, alcohol or drug treatment,
and HIV/AIDS records. Physicians should have patients sign a separate and specific request form for the
release of this information. If a request is made for a copy of the record, and the patient has not given a
specific consent for this information, that information should be excluded from the copy that is sent to
the requestor.
Slide 51
As a general guideline retain records 10
years from last patient encounter.
Record retention guidelinesChildhood immunization Permanently
Legal disability Permanently
Records in malpractice claimPermanently
Physicians and office managers often wonder how long to keep a patient’s medical record. As a general
guideline, ISMIE recommends that physicians retain records for 10 years from the last patient encounter.
This 10 year rule is based on the requirements of the Hospital Licensing Act. There are a few
exceptions: childhood immunization records, patients with a legal disability and records involved in a
medical malpractice claims should be kept permanently.
Slide 52
Consider an Electronic Medical
Record (EMR)
Advantages over paper-based systems:
..Reduces paperwork
..Prompt and convenient record retrieval
..Provide prompts for specific findings, reminders
about preventive testing
..Warnings about contraindications and drug
interactions
..Tie to practice management systems to minimize
allegations of fraud and abuse attributable to
billing
More physicians are turning to the electronic medical record as a means for documenting patient care.
There are many advantages to an electronic medical record system, in that it reduces paper work, and
provides prompt and convenient record retrieval. Most systems can flag specific findings and reminders
about preventive testing. Warning alarms can alert the physician to contraindications and drug
interactions reducing the likelihood of a medication error. Some systems can integrate with practice
management systems to assimilate billing and medical record systems.
Slide 53
Advantages over paper-based
systems (cont’d)
..Accessible to physicians on call or away from the
office
..Permits simultaneous access by multiple users
..Interfaces with PDAs for functions of patient
tracking, prescribing, drug interactions, test results,
billing and coding
With an EMR, physicians can have access to a patient’s medical record from remote locations and
multiple healthcare providers can be looking at the patient’s record at the same time. Some EMRs
interface with PDAs for patient tracking, prescribing, drug interactions, test results and billing and
coding.
AARISKMANAGEMENTDocumentation Workshop
Welcome to OUR Risk Management Documentation seminar. This seminar is part of OUR COMPANY
Managing Risk program designed to help physicians implement effective risk management techniques
into their daily medical practice. This program is also one of the requirements for the OUR COMPANY Fellowship
Program.
Slide 2
Risk Rewards Program•1% premium discount for completing
this activity•To qualify, you must:
..Complete entire program
..Achieve 80% minimum passing score
..Not have completed this program in
2004 or 2005
By successfully completing this seminar you will receive a one percent discount on your OUR COMPANY Mutual
premium. To receive the discount, you must achieve a minimum of 80% on the test at the end of this
program. To receive the discount for this program, you cannot have completed this program in 2004 or
2005.
.............
..............................
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Previous projects - email or chat.
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