“It used to be that medical records were just about remembering treatments and what the patients said, and passing along info to colleagues. Today it is about so much more,” says Isabelle Bibet-Kalinyak, a healthcare attorney from Ohio. “Medical records are now a major source of risk and compliance traps.”

Bibet-Kalinyak spoke at the most recent meeting of the Medical Group Management Association, sharing insights into the changing role of medical records. It was no surprise to find the importance of good charting at the top of her list.

Most Common Charting Pitfalls

With the widespread use of electronic health records, errors and omissions in medical records “should be a thing of the past, but no,” she said. Studies are still showing that two of the biggest failures in medical records are 1) failing to put in required information, or 2) amend relevant information.

“We also see a lot of inaccurate data and we still see issues of professionalism,” Bibet-Kalinyak added. That’s not all. The most common mistakes healthcare attorneys see in practice include:

  • Omitting required information
  • Omitting relevant information
  • Inaccurate data or errors
  • Professionalism
  • Illegible records or signatures
  • Wrong or too many abbreviations
  • Misunderstandings of coding language and standards

“These are the basics,” said Bibet-Kalinyak, “and we shouldn’t still be seeing these.”

If your practice is still struggling with issues like these, correcting them should be your first line of defense. Beyond this, she pointed out other issues that some providers may not be as aware of, including the following:

Patient Contact: Any time a provider or member of the staff contacts the patient, the interaction should be included in the chart. “If they speak to the patient by phone or by other means—some providers give out their text number—document this.”

Staff in the room: If there are any other providers or staff in the room with you during a patient encounter, it should be noted in the records.

Family/friends in the room: “If the patient’s family is there, then make notes about who is in the room and what was discussed.” This is especially important in the areas of informed consent for treatment and associated risks, as well as conversations where treatment choices are made.

Informed consent: Before any treatment or procedure, there should be documentation of informed consent.

Compliance: Document any instance of the patient refusing treatment or not following through. This is particularly important in a hospital setting when a patient self-discharges or goes “Against Medical Advice.”

Potential Complications: Potential side effects or complications should always be discussed with the patient and this should be documented. “We are seeing more lawsuits stemming from the lack of providing adequate warning.”

Medical Necessity: Documentation must demonstrate that a service or procedure is required, in what quantity, and whether the provider is the most cost-efficient professional to provide the service.

Without a doubt, the weight and complexity of medical records keeps changing and it can be hard to keep up. But just as you would batten down your ship’s hatches, master these basics and you’ll be better able to weather any coming storms.

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