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Onboarding Medical Assistants and Office Staff Toolkit

Advisories on documentation

Scribes, old concept-new role

In light of the many challenges today’s physicians face, their managers are dusting off the old concept of “scribes”. Some providers find that the use of scribes helps them meet increased time demands while maintaining the good quality of care they desire to deliver. Scribes working in healthcare today are assisting physicians with duties that include all aspects of a patient’s visit.

According to the information paper, Use of Scribes, developed by the members of the Emergency Medicine Practice Committee, scribes were used as early as the 1970s during the implementation of electronic records. Scribes’ education and training vary.  Some scribes are registered nurses, others are pre-med students, and in some cases, medical assistants. With regards to the electronic health records, physicians have expressed concerns such as, “The focus seems to be on reimbursement instead of the provision of quality care” and “My productivity has decreased, and I am not able to capture the information that I was before we were using the computer documentation.” Due to these and other frustrations, the use of scribes to assist providers with medical record documentation is gaining popularity. According to Lewis in Medical Economics[i], a scribe can assist physicians by:

  • transcribing details of the physical exam
  • recording physician’s consultations with patient, family members and others
  • navigating the electronic health record
  • documenting procedures performed
  • checking the progress of and reviewing lab, x-rays, et cetera
  • recording physician-dictated diagnoses, prescriptions and instructions for patient discharge and follow-up

Risk Management Commentary

The Joint Commission (TJC) does not support the use of scribes to enter orders for physicians or practitioners due to the additional risk added to the process.[ii] Organizations that choose to use scribes are required to demonstrate compliance with a number of TJC’s standards in Human Resources, Information Management, Leadership and Rights and Responsibilities of the Individual.

The TJC standards[iii] referenced above include but are not limited to:

  • A job description that recognizes the unlicensed status and clearly defines the qualifications and extent of the responsibilities (HR.01.02.01, HR.01.02.05)
  • Orientation and training specific to the organization and role (HR.01.04.01, HR.01.05.03)
  • Competency assessment and performance evaluations (HR.01.06.01, HR.01.07.01)
  • If the scribe is employed by the physician, all non-employee HR standards also apply (HR.01.02.05 EP 7, HR.01.07.01 EP5)
  • If the scribe is provided through a contract then the contract standard also applies (LD.01.03.09)
  • Scribes must meet all information management, HIPAA, HITECH, confidentiality and patient rights standards as do other hospital personnel (IM.02.01.01., IM.02.01.03, IM.02.02.01, RI.01.01.01

The CMS directs that scribed documentation services include the following:

  • Who performed the service
  • Who recorded the service
  • Qualifications of each person
  • Signed and dated by both the physician and the scribe[iv]

Organizations should also review the requirements of third party payers as they may have specific guidelines for the documentation completed by scribes. As the prevalence of scribes increases, the potential for expanded legal guidance grows. 

Risk Management Suggestions:

The implementation of new or revised processes in an organization such as the hiring of scribes presents new challenges and risk exposures that should be considered and managed appropriately. 

Prior to hiring scribes, organizations should[v]

  • Review individual state law to ensure compliance and proper use of scribes by physician extenders
  • Orient and train the scribes specific to the organization and role
  • Complete competency assessment and performance evaluations
  • Restrict the use of verbal orders to scribes or by scribes
  • Require identification to reduce confusion by patients
  • Require all entries in the medical record are signed and dated
  • Require providers to review information prior to authentication
  • Develop a contingency plan in the event scribe is not available

Today’s healthcare environment of increased regulations, documentation incentives and reimbursement requirements continue to impact providers and organizations. Organizations and providers are searching for resources that will allow them to provide safe quality care while meeting the demands required by multiple regulatory sources.

Scribes may have a new role in healthcare. By applying sound risk management principles to their practices, scribes may enhance a physician’s efficiency and improve patient safety efforts at the same time.

[i] Lewis, M. Medical Economics. Scribes can help document care, boost efficiency at medical practices. Oct 10 2013.

[ii] The Joint Commission.”Standards FAQs.” May 2011.

[iii] The Joint Commission, “Standards FAQs.: July 2012

[iv] Cahaba Government Benefit Administrators, LLC. Guidelines for the Use of “Scribes” in Medical Record Documentation Reminder. April 11, 2013.

[v] AHIMA. Using Medical Scribes in a Physician Practice. Journal of AHIMA 83, no. 11 (November 2012): 64-69 [expanded online version].

Copy and paste documentation creates a problematic defense

A middle aged man presented to his primary care physician’s (PCP) office with symptoms of panic attacks, intermittent chest and lower jaw pain. The patient was overweight, had hypertension, high cholesterol, an enlarged heart, drank alcohol daily, and smoked. A week later he called back with symptoms of shortness of breath, chest pain radiating to the neck, shoulders and jaw. The physician’s office advised him to go to local hospital’s Emergency Department (ED). In the ED, the patient’s EKG was abnormal, showed atrial fibrillation, evidence of septal infarct, marked ST abnormality, and possible inferior subendocardial injury.

The patient was discharged from the ED with a diagnosis of chest pain, unknown cause, and cardiac arrhythmia. Discharge instructions included to follow-up with the PCP in the morning, and to have a (stress) treadmill test.

Upon returning to the PCP, the patient’s blood pressure was 170/100. The PCP was aware the patient had been in the ED; she had the ED notes and discharge instructions. Her assessment was chest pain, unknown etiology, anxiety/depression, panic attacks, and atrial fibrillation. At this office visit, she prescribed Lanoxin 0.25mg daily and Glyburide 2.5 mg. No stress test was performed or ordered.

At his next visit to the PCP, two weeks later, the patient’s B/P was 150/90. The PCP now diagnosed insomnia, COPD, and diabetes mellitus. She prescribed Xanax 0.5 mg every 6 hours PRN x 100 and vitamins.

The PCP’s plan note read, “Call PCP or go to ED if signs/symptoms don’t improve. Discussed side effects and precautions about medicines; advised about low salt/low fat/low sugar diet, written material handout, also advised about daily exercise, injury prevention, self body examination, lifestyle modifications, reduction of stress and counseled about high risk sexual practices, family planning, domestic violence, substance abuse, addiction, etc. Follow-up in one week, or as needed. Call if no relief.”

This same plan note was repeated in the next twelve office visit record entries that followed for the next two years the patient was under this PCP’s care. No new medications were added to the patient’s regimen. No cardiopulmonary work-up, including a stress test, was ever performed.

The patient continued to follow up with his PCP as directed, complaining intermittently of shortness of breath, anxiety, depression and panic attacks. One evening, shortly after eating dinner, the patient collapsed. Emergency Medical Services found the patient on the floor, unresponsive. Resuscitative measures were unsuccessful.

On the death certificate the PCP listed the patient’s cause of death as cardiac-respiratory arrest, chronic obstructive pulmonary disease and cardiac arrhythmia.

The Allegations

It was alleged that the PCP deviated from the standard of medical care, and that this deviation led to the patient’s death.

Specific allegations against the PCP included:

  • Failed to appreciate hypertension, high cholesterol, past MI and Diabetes as indications of increased cardiovascular risk;
  • Failed to diagnose and measure the increased risk of MI, stroke and cardiovascular risk;
  • Failed to inform and educate the patient
  • Failed to initiate specific advice and treatment known to significantly decrease the risk of MI, stroke and cardiovascular death.

Disposition:

We were unable to secure expert support for the PCP. The case settled for a high dollar amount.

Risk Management Commentary & Advice

In general, the standard of care for determining medical malpractice is based on how a similarly qualified practitioner would have performed under the same or similar circumstances.

The PCP had no plausible explanation for why she did not work up the patient’s cardiac complaints or refer him out to a cardiologist for a stress test. She merely stated that she had advised the patient to find a cardiologist who could do an appropriate work-up. However, she did not document this conversation anywhere in his chart, she did not make a referral to a cardiologist, and she did not track for patient compliance over the two year period she was seeing the patient in his office.

  • Documentation shortcuts available with Electronic Health Record systems are tempting for busy clinicians. The ability to have template-type documentation makes physicians more effective and efficient and is essential, but the inappropriate use of templates, such as “copy and paste," can be a problem. In this case, the PCP’s practice of “copy and paste,” or the pulling forward of information from past visits, appears to have resulted in some misrepresentation of each subsequent patient visit. Carrying forward information without careful review can cause contradictions in a patient’s chief complaint. Certainly, the integrity and credibility of this PCP’s record was affected by the documentation shortcuts she took. Physicians are encouraged to customize medical records to the greatest extent possible, even in a template system, so it's obvious to reviewers that they are not “carbon-copying or cloning” records. A detailed documentation of the patient's chief complaint, which should carry through to the physical exam and the history, should always be used to support decision making and medical necessity determinations.
  • If the physician’s concerns don’t match the patient’s, the patient is likely to feel marginalized. If the physician’s decision process is not well documented, an allegation of substandard care is more difficult to defend. Clarifying the patient’s key concerns and his or her understanding of the diagnostic process can close any gaps between the patient’s expectations and his physician’s.
  • Fully appreciating the circumstances surrounding an encounter is generally impossible without written evidence. Explaining why certain tests were ordered and not others is instrumental in understanding the disposition of the patient. Unfortunately in this case, the reasons for not pursuing a cardiology work-up in a patient with such high risk factors and ongoing symptoms cannot be well explained or defended.
  • This patient was given instructions, including those specific to chest pain. However, patients may set the bar higher before they will go to the ED, even in the face of more troublesome symptoms. Patients may present to the ED more willingly if they’ve been properly instructed on how to appropriately respond to various symptoms or circumstances.

Making corrections to the medical record

Every practice should establish a policy and procedure for correcting medical records, whether paper or electronic (EHR). A correction is a change in the information meant to clarify inaccuracies after the original document has been signed or completed. It is acceptable to make an addendum to a medical record. It should be made after the last entry noting the current date and time, and both entries should be cross-referenced. A record that appears to have been altered implies that a cover-up has occurred. Never improperly or unlawfully alter a medical record.

If an error has been made in a paper record, draw a single line through the inaccurate entry and enter the necessary correction. Enter the date and time and initial the correction in the margin. Questionable medical record corrections or additions, e.g. notes in the margin, writing between the lines, erasures, etc. should be avoided.

Correcting errors in the electronic record should follow the same basic principles as correcting errors in paper copies. The following specific considerations apply to the EHR.

  • Work with your vendor to confirm that your EHR system allows error correction, and whether or not the vendor has established a process.
  • The system should have the ability to track corrections or changes once the original entry has been entered or authenticated.
  • When correcting or making a change to an entry, the original entry should be viewable, the current date and time should be entered, the person making the change should be identified, and the reason should be noted.
  • In situations where there is a hard copy printed from the electronic record, the hard copy must also be corrected.
  • The process should permit the author of the error to identify, and time/date stamp, whether it is an error.
  • The process should offer the ability to suppress viewing of the actual error but ensure that a flag exists to notify other users of the newly corrected error.
  • The location of the error should also point to a correction. The correction may be in a different location from the error if there is narrative data entered, but there must be a mechanism to reflect the correction.

Our suggestion is that you develop a practice policy, and train your physicians and staff to ensure that your facility corrects and reports errors in a consistent and timely manner.

Timely dictation, review, and filing of reports

 

To facilitate continuity of patient care and ensure corporate compliance, it is recommended that medical practices establish an organization-wide policy to track and address medical record delinquencies, and ensure that dictation, transcription, and the filing of medical records are completed accurately and in a timely manner. Medical record statutes, regulations, and accreditation standards all require healthcare providers to maintain complete records. The medical record serves as the main communication tool between all members of the healthcare team. The medical record should support and help coordinate the medical care of a patient.

Timely dictation, review, and reconciliation are important in facilitating the flow of information among the providers involved in the patient’s care. In today’s complex healthcare delivery environment, requiring an exceptional amount of coordination among the various providers involved in the care of a patient, it’s easy to see why communication errors are frequently cited as one of the leading causes of medical errors.

Obtaining and analyzing medical records is a critical component when reconstructing the medical treatment of a patient. Approximately 35-40% of all medical malpractice suits are rendered indefensible because of problems with documentation in the medical record and/or the management of the medical record in general. A complete record, with factual, objective documentation of the care rendered, is the provider’s most effective defense in the event that the provider is sued for medical malpractice.

As part of the discovery process, lawyers may request not only printed copies of the electronic health record (EHR), but also the audit trail for metadata analysis. This includes logon and logoff times, what was reviewed, and for how long, what changes or additions were made, and when those changes were made. A record entry completed long after a patient encounter, or at the time an attorney is requesting the medical record, is likely to hurt that provider’s defense.

It is clear that inadequate, incomplete, or untimely completion of medical records expose the physician and the hospital to risk. Hospital rules and regulations and medical office policies and procedures should be strictly enforced to enhance patient care and to avoid potential legal exposure.

Vital signs: vitally important

Errors in diagnosis, failure to supervise or monitor case, and failure to recognize a complication of a treatment are among the top five most prevalent medical factors associated with medical liability claims.1 Further, for those cases in which an associated medico legal issue was included in the allegation against the practitioner, problems with a patient’s history, exam or work-up was most prevalent.2

Below are some of the more common factors leading to diagnostic errors:

  • Inadequate patient-provider communication
  • Incomplete medical history documentation
  • Failure to examine the patient
  • Failure to order diagnostic tests
  • Follow-up and tracking diagnostic information
  • Interpretation of tests
  • Patients not referred to a specialist

Accurate, documented vital signs are an important component of patient care. They provide essential, baseline data for treatment decisions and historical trends. This historical information allows for recognition of acute or chronic changes that may prove significant.3 Ignoring basic findings, such as vital signs, is a common factor that leads to diagnostic error. These lapses interfere with appropriate and timely interventions for deteriorating patients. All too often physiologic abnormalities that develop up to 24 hours prior to death are either undocumented or unrecognized.

In the medical office setting, at minimum, vital signs should be taken and recorded for patients presenting with an acute illness, procedures, and high-risk treatments.

Critical tests

 

Healthcare organizations continue to struggle to ensure that critical findings are communicated and acted upon in a timely manner. Approximately 40 percent of patient encounters in primary care offices involve some form of medical test. Studies of primary care offices consistently show that the process for managing tests is a significant source of error and patient harm.1

The Joint Commission has prioritized safe and timely communication of critical tests as a National Patient Safety Goal (NPSG.02.03.01), “Report critical results of tests and diagnostic procedures on a timely basis.” The definition of a critical test varies but may be described as those that require rapid communication of results regardless of findings such as normal, abnormal, or critical. A critical test result may also be defined as “any result or finding that may be considered life threatening or that could result in severe morbidity and require urgent or emergent clinical attention.”2 For practical purposes, it is important to recognize that critical test results may vary by specialty; for example, a nephrology practice may not consider a potassium level critical unless it is higher than 5.1. However, a primary care physician or cardiologist may have a different threshold value.

Providers are encouraged to design reliable processes that recognize and address opportunities for system failures. In doing so, the practice will be better equipped to improve patient safety and reduce the risk of a professional liability claim. Components of a well-designed system for the management of critical tests should include the following:

  • A list of tests and results that require timely and reliable communication
  • A process for immediately conveying critical results to the responsible provider or a surrogate if the responsible provider is not immediately available
  • A mechanism to ensure that test results are reviewed timely and acknowledged by the provider
  • A process for patient notification of test results which includes documentation in the medical record
  • A process that ensures follow-up of any additional testing or monitoring required/needed

Additional recommendations regarding the management of critical tests and results includes orientation and ongoing education of all members of the healthcare team on procedures for communicating critical tests and/or results, ongoing monitoring of the effectiveness of the system and patient engagement.

Health care organizations should continue to develop and redesign processes as needed to ensure safe and timely test-result communication in order to reduce risks and effectively ensure quality patient care.

Disclaimer

The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.