Discussion Objectives:

• Review healthcare compliance material, and its application in the delivery of care  
• Reflect on reading and understand concepts through engagement and dialogue to enhance learning 
• Expand classroom learning by using healthcare administration review information explore conceptual thinking 

First response is due on or before Wednesday 11;59pm

Subsequent discussion /responses due Thursday – Saturday 11;59pm

Discussion closes Sunday 11;59pm

Case Study:  An HIM graduate with two years of experience is employed by a large academic healthcare center and is placed in a management position over the Analysis and Chart Completion area. Using the reports generated by the IS Department to calculate the chart delinquency rate, she determines some “incomplete charts” are over 30 days old. The charts are in a pending file and are not counted in the total number of delinquent records. “If these records were counted, the delinquency rate would be above the required standard by the Joint Commission”.

Step #1 ; Respond to the following question-

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• Is there an ethical violation, dilemma, or concern by these incomplete medical records ( delinquent) ? Explain your answer with examples in 150 words discuss the law or policy surrounding documenting a medical record timely 

Step #2;  Read the following information and discuss with your classmates –

1.  
1. Is it important to have a policy on how soon a chart be completed and why? 
2. What implications do you think you as an Administrator will face from Hospital Management as well as Hospital Board? 

Do you think there are any legal violations if a record is not completed within a given time period, yes or no and support your answer in 100 words 

No Chart Left Behind: Read about deadline to Complete Medical Records:  Medicare has no stated time policy about how soon after a service is performed on a Part B fee-for-service patient that it needs to be documented.  The Medicare Claims Processing Manual says only “The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”

• We can probably all agree that “weeks later” is not “as soon as practicable after it is provided.”
• Many groups suggest that visits are documented the same or next day, and mandate that all are documented within three days.
• Consider a policy that for visits documented and closed after a certain time period (7 days? 14 days?) the physician won’t be given RVU credit.
• There is no regulation in the Claims Processing Manual that states the visit must be documented before the claim is submitted.  Some groups have this policy in place.  In my opinion, I don’t think a group needs to hold claims unless there is a problem.  Most clinicians finish their notes in a reasonable period of time.   If the charge is submitted the day before the note is signed off, this isn’t a problem.  But, if there is a clinician who is regularly behind or who neglects to document for some visits, don’t submit claims until the documentation is complete.
• Increased training on the EHR will often help a clinician to complete notes more quickly.  There are shortcuts in all systems, and some clinicians haven’t found them and haven’t been trained.  In groups of clinicians I often hear “Oh, don’t you know how to look that up from the visit page? You don’t have to open a new window….”
• Consider allowing physicians to dictate into the HPI and comments into the assessment/plan section.  It adds value to the note.
• Look at the schedule: is it optimal?

Incomplete notes are a quality of care issue as well a compliance and billing issue.  Medical practices that find themselves in this situation need to address and solve the problems quickly. Because, if a clinician is weeks behind finishing records, how accurate will the notes be when they are finished?