Purpose of Paper
The purpose of this paper is to emphasize the need for medical charting and discuss about the federal and state laws enacted to mandate the need for Medical Charting. A medical chart is a highly confidential documentation where the personal and well detailed information of a patient and care progress of the patient. It strictly contains demographics, patient’s notes, diagnoses, surgeries treatment plans, allergies, radiological studies, test results, immunization records, patient’s habits and patient’s consent forms. The following are not expected to be stored in the medical chart of a patient; peer review note, general notes, correspondence to malpractice carrier and other items. At each medical check-up, vital information such as chief complaint, present illness history, physical examination such as vital signs and organ system review, etc. are meant to be added to the patient’s medical chart (Care Cloud, 2017; Christopherson, 2008).
Each patient’s medical charts are supposed to be handled with extreme care, hence, only the patient and concerned team member of the healthcare have access to the confidential medical chart. According to the HIPAA regulation, a patient has the right to ensure accuracy of the information in a medical chart and also grant a third-party access for accuracy check. This is meant to correct or adjust wrong medical input towards perfect or accurate record documentation. In recent time, electronic health record EHR makes it easier and faster to document and make available health information for patients and other member of the care team by the provider (Care Cloud, 2017). EHR helps physicians to have quick access to important health information they need about a patient for quick decision to be made. It helps to reduce errors in charts caused by poor penmanship, improves accuracy and clarity of care coordination with a guarantee that medical charts can never be lost (Care Cloud, 2017).
All medical charting must meet the requirement for the Medicare Conditions of Participation 42 CFR Section 482.24 as shown in the pictures below as required by the federal law.
“Medical Record content must meet all State and federal legal, regulatory and accreditation requirements inclusive but not limited to Title 22 California Code of Regulations, sections 70749, 70527 and 71549, and the Medicare Conditions of Participation 42 CFR Section 482.24.”
The specific targeted employee group and specific health services setting
The specifically targeted employee is Mrs. Karen Matin who is presently working with The Arc of PG County in Largo Maryland for close to 15 years as Human Resources Administrator. She is responsible for managing and administering benefits for the staffs. The organization has over 300 employees under her supervision and she ensure all staff status changes and updates are input in our HRIS system. She was responsible for ensuring certain staff obtained and maintained their Certified Medication Technician Certification. She also monitored Certified Nursing Licenses, LPN, RN licenses to ensure they were current.
If a CMT expired staff was unable to give meds and had to retake the 20-hr class. If a CNA, LPN or RN expired, staff would be placed on unable to work status until their license current.
Charting errors resulted in staff being sent to documentation training. On-going errors resulted in termination. Medication errors can result in termination.
I chose this organization because they are responsible for the effective care of patients with disability and proper documentation is required. There the federal and state law requirement for medical charting must be strictly followed. The state law that should be followed or complied with is the Code of Maryland Regulations (COMAR) with Maryland Department of Labor, Department of health and Developmental Disability Administration.
Failure to comply can result in a DDA investigation and corrective action plan. There are instances where medical modification of record is required for accurate charting even though this must be done with the consent of the patient and the health care personnel. Nevertheless, there is authority stating that a hospital may not permit a doctor, despite the agreement of the patient, to do so except the change serves as a supplement or correction that does not alter a prior entry (Christopherson, 2008). According to Mrs. Karen Matin, administrative consequences are involved for failure to comply such as administrative leave which may eventually lead to termination of the appointment.
The following duties must be carried out by employees in compliance with the law,BDate and time should be included on all entries into the record.
A person’s full name and other identifiers (i.e., medical record number, date of birth) should be included on all records.
- Each page of documentation should be signed.
- Blue or black non-erasable ink should be used on handwritten records.
- Records should be maintained in chronological order.
- Disposal of any records or portions of records should be prevented.
- Documentation errors and corrections should be noted clearly, i.e., by drawing one line through the error and noting the presence of an error, and then initialing the area.
- Excess empty space on the page should be avoided. A line should be drawn through any unused space, the initial, time, and date included.
- Only universally accepted abbreviations should be used.
- Unclear documentation such as illegible penmanship should be avoided.
- Contradictory information should be avoided. For example, if a nurse documents that a person has complained of abdominal pain throughout a shift, while a physician documents that the person is free of pain, these discrepancies should be discussed and clarified. The resolution should be entered into the chart and signed by all parties involved in the disagreement.
- Objective rather than subjective information should be included. For example, personality conflicts between staff should not enter into the notes. All events involving an individual should be described as objectively as possible, i.e., describe a hostile person by simply stating the facts such as what the person said or did and surrounding circumstances or response of staff, without using derogatory or judgmental language.
- Any occurrence that might affect the person should be documented. Documented information is considered credible in court. Undocumented information is considered questionable since there is no written record of its occurrence.
- Note in the chart any missed appointments, consents completed and release of information forms.
- Current date and time should be used in documentation. For example, if a note is added after the fact, it should be labeled as an addendum and inserted in correct chronological order, rather than trying to insert the information on the date of the actual occurrence.
- Actual statements of people should be recorded in quotes.
- The chart shouldn’t be left in an unprotected environment where unauthorized individuals may read or alter the content
- Avoid including witticisms or personal comments (“This patient is a grouch!”) in medical records. Things that seem amusing to you at the time you write them may not be funny to a potential jury.
- Avoid changing an entry in order to tone down an overly critical observation of a patient’s personality or behavior. “Cosmetic” changes are not necessary for patient care and should not be made at any time. (Christopherson, 2008)
Case Studies and Employee Responsibilities.
A particular doctor internist failed to complete the medical charts for 59 patients, even though the management had given warnings. Due to this, his license was revoked by the state medical board and company privileges were withdrawn. He was also fined a sum of 2000 USD and mandated to take 20 CME hours in risk management and record-keeping. This is a lesson that hospital record-keeping is important and done immediately after treatment. One of the reasons for this is because third parties won’t pay for care given to patient without a duly filled record.
Another scenario is the case of a psychiatrist who admitted three patients on an emergency ground, but she didn’t write admitting notes until several weeks later. Her case was reported to the state medical board because state bylaws require admitting notes to be documented within 24 hours. She was fined 2500 USD and mandated to take five CME credits in risk management and record-keeping.
A gynecologist filed an insurance claim for a total abdominal hysterectomy although, he was to meant to perform a right salpingo-oophorectomy surgery. The state board, after been notified by the hospital, charged him with failing to maintain adequate records, practicing below the acceptable standard of care, and filing a false report. Therefore, it is important to dictate the right notes on procedures when the memory is fresh, because it wasn’t his fault but bad medical chart presented to him (Economics, 2006).
Medical charting is very important because it is the total record valid for medical and legal purposes for individual’s clinical status and the involvement of caregivers. It determines a patient’s health life for every stage in his healthcare. The involvement of whatever method be it paper or electronic method must not rule out the confidentiality aspect of the medical record document, hence the right steps should always be taken to avoid administrative and legal charges against doctors, nurses or caregiver involved.