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Timely Completion and Signing of Medical Records . American College of Osteopathic Internists

Electronic Medical Records

It's nothing new. Compliance with verbal orders has been a struggle for hospitals for more than 25 years. Many experts Hospital Peer Review spoke with compare verbal-order compliance to hand-washing compliance. It's behavioral. It's something we know we have to do. And it's not a matter of ill-intentioned practitioners. It's a matter of time and logistics.

While the issue of legibility has been largely addressed by increased utilization of electronic health records EHRscompletion of the record through the inclusion of proper documentation and a dated signature continues to be of concern.

What does it mean for a medical record to be complete? Is the record complete when it contains the documentation of the patient encounter but is not signed and dated?

As you know, you should not bill for an office visit or other service until documentation is on file supporting the level of service or code indicated for billing. The file is not complete until the proper documentation is accompanied by a dated signature. As such, an auditor knows exactly when the signature of the provider was placed in the record. How long is too long after the care is provided? As a result, the answer as to timing varies from region-to- region. Check with your MAC.

In general, it is best to sign the record at the time of service, if not within a day or two at the latest. Signatures beyond a couple of days increase the likelihood that a claim will be denied because necessary documentation will not be accepted as being present due to a signature and date too removed from the time the care was provided.

This could be disastrous and costly in an audit. As a result, there would be no accepted documentation for the visit and payment would not be allowed even if an attestation statement was added at a later date.

To safeguard against these potential pitfalls, your practice should have policies that filing for services occur only after documentation is complete — including a dated signature. So what can you do to get your compliance rates up?

As it is now, Joint Commission-accredited hospitals must have verbal orders authenticated, timed, and dated within a hour time frame.

And that authentication can be handled by covering physicians. Of course, stipulations can vary state to state. According to its interpretive guidelines, beginning inno one but the prescribing provider can sign verbal orders. And everyone expects that The Joint Commission will fall in line with this, though, Ken Powersmedia relations manager, says, "The Joint Commission will see what CMS implements before determining a response.

Dating and timing medical records

You should have a policy in your hospital's rules and regulations that essentially discourages verbal orders, that states the use of verbal orders should be minimized and reserved for emergency situations, says John R.

You must have this stated in your regulations, and he says The Joint Commission will want to see that. If you can't locate that or if it's not included, you might be cited. One challenge is to decrease the overall number of verbal orders that are given in a given day, reserving them for emergency situations, procedural times, and middle-of-the night emergencies.

That will decrease the overall requirement burden just by the sheer number of orders that have to be dealt with," Elzer says.

or other entries in the medical record that are not legible may be misread or The requirements for dating and timing do not apply to orders or prescriptions that. The medical record should be complete and legible. 2. The question is most important because EHR systems do not allow for back-dating of a signature. As a result, the answer as to timing varies from region-to- region. Dating and timing entries. All entries must be dated and timed. Dates will be written in the day–month–year sequence; months will be stated by name, not by.

Kienle says the hospitals she visits that are most successful have ratcheted down the number of verbal and telephone orders. But this "takes a culture shift," she says. And there always will be situations where verbal or telephone orders are necessary.

Joint Commission surveyors will check charts along their tracers, but they also will ask providers, "'How do you take a telephone order if you need to?

What's the process you walk through? But sometimes we might be down the hall or somewhere where we can't get the chart. Nonetheless, we write it down and then we read it back to the physician for confirmation. And if it's read, you're in good shape.

If it's repeat, you're going to be in trouble," he says. Compliance, Elzer says, is a combination of many things. You talk to the docs and say, 'What would have helped you better do this? Many hospitals have implemented fines for noncompliant practitioners. Some find that helpful; some find it unnecessary. Usually the first step in becoming compliant is flagging, Elzer says — flagging orders that have to be signed and color coding the flag to identify which group of practitioners need to look — for instance, red for heart surgeons and blue for ED physicians.

But, she says, "some organizations that have dealt with this on a long-term basis haven't been able to get the physicians to turn around by gentle reminders.

And they start looking at, 'How can we kick this up a notch? Some hospitals, she says, have stipulated that if your verbal compliance is poor, providers must pay more of their dues, or discounts for dues are waived.

RC makes the top 10 list for the third year which outlines the actual components of the medical record, were related to dating and timing of.

It's an irritation factor," she says. Rosing says some organizations he's worked with have found innovative ways to incentivize physicians to be aware of verbal order requirements.

And just make a big deal about certain people who have improved over time," he says. He helped one hospital find a unique and humorous way to bring physicians into compliance. He found cards that play a customized recorded message when you open them.

They recorded an MP3 file and attached the card to charts so when physicians opened them, they would hear the eight-second recording: "Please sign, date, and time your verbal orders.

Be aware that it can sometimes take a dating and timing medical records or two to obtain those records, and. Dec I say that phrase at least 10 times a day: . Signing, dating, and timing your verbal orders: Are you in compliance? paper, preferably we have the chart with us — and we write it in the order section. You have the privilege to order medical treatment, and this is part of. Any changes made to the medical record must leave an “audit trail” by lines that leave the old information legible, and dating, timing, and signing the change.

Damn it! But Kienle finds punitive measures such as fines and removing cafeteria privileges a "Draconian move. But we're all professionals, and that carrot and the stick thing just doesn't do much for me, especially on the punishment side," she says.

Medical records and data-driven healthcare

She finds more success "if administration is clear in their intent to truly do this for the right reasons. You know, that it's a safety issue. We want to avoid misinterpretations. Rosing thinks it's helpful for someone the physicians respect to speak one on one with them, whether that be the vice president of medical affairs, the chief medical officer, or an administrator.

Dating and timing medical records

He suggests telling physicians, "'Hey, this is simply a requirement that we have to fulfill. And we need your assistance.

DATING, CORRECTING, AND MAINTAINING THE CHART t is extremely 3very time a patient is given a prescription over the phone or is given a report or. While Happn uses your results by Last logged in, you ll have dating and timing medical records go ahead check your email address each time you visit our. Feb The medical record should be complete and legible.

How can we make it easy for you? But bear in mind, we're not going to waste our time doing this if you're not going to pony up and sign it. So it's a two-way street on that,'" he says. The other thing he suggests that resonates with physicians on a personal level is to say, "When you don't sign a verbal order, you're compromising your colleague," putting that coworker at risk by carrying out something that wasn't authorized by a licensed independent practitioner.

To say, 'Look you're being disrespectful here… you're putting the nurse in a compromised position and that's not fair to them.

You need to hold up your end of the bargain and carry out your responsibility. You went to medical school.

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