Hospitals, physician organizations, managed care organizations, insurance companies, the government… everyone, it seems, has for years been on the rampage about delinquent medical records.
The medical staff rules and regulations of most hospitals contain provisions that allow for the warning and then the discipline of practitioners who do not comply with the requirements for the timely completion of medical records. Under most HMO and PPO agreements, managed care organizations may ultimately terminate physician providers if they repeatedly fail to complete the medical records of the organization’s patients. Insurance companies and governmental payment programs may generally deny reimbursement if medical records are not complete when a claim is processed for payment. Thus, many practitioners belatedly comply with the rules on delinquent medical records, complete overdue charts when the threats of discipline or suspension intensify, and simply live with the sluggish cash flow that may result from procrastination or delays in record completion.
A recent clarification from the National Practitioner Data Bank, a confidential national clearinghouse for adverse action and professional liability reports on physicians and other practitioners, may encourage practitioners to complete their medical records on time. The current Data Bank Guidebook indicates that a 31-day suspension, based on a physician’s incomplete medical records, would be reportable “if the failure to complete medical records related to the physician’s professional competence or conduct and adversely affects or could adversely affect a patient’s health or welfare.” In response to this example, most hospitals and other reporting entities have taken the position that medical record suspensions are administrative actions, rather than professional review actions, and thus have not reported medical record suspensions of more than 30 days to the Data Bank.
The definition of a “professional review action” is critical in determining whether a medical record suspension of more than 30 days is reportable to the Data Bank. The Health Care Quality Improvement Act defines a professional review action as “…an action or recommendation of a professional review body which is taken or made in the conduct of a professional review activity, which is based on the competence or professional conduct of an individual physician (which conduct affects of could affect adversely the health or welfare of a patient or patients), and which affects (or may affect) adversely the clinical privileges of the physician.
The recent clarification from the Data Bank indicates that “a failure to complete medical records generally is related to a physician’s professional competence or conduct and almost always has the potential to adversely affect a patient’s health or welfare.” With these words, the Data Bank seems to be warning hospitals and other concerned reporting entities that medical record suspensions may generally be professional review actions, rather than administrative actions. The Data Bank clarification also states that its position will be further “clarified” in future editions of the Data Bank Guidebook. Thus, practitioners should beware.
The requirements for timely medical record completion are well established in the law and through industry accreditation standards. The federal regulations known as the conditions of participation for hospitals participating in the Medicare program contain specific requirements about medical records. For example, medical records must be maintained for every individual who is evaluated or treated at the hospital. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. Evidence of a physical examination, including a health history, performed no more than seven days prior to admission or within 48 hours after admission, must be present. Medical records must be completed within 30 days following discharge and must include the final diagnosis.
When surveyors for the Medicare and Medicaid programs come on site to a facility (whether to investigate a patient complaint or to survey the hospital for compliance with Medicare requirements), the surveyors generally pull a large sampling of patient charts. If a pattern of incomplete medical records is identified, the hospital’s certification to receive payment for treatment provided to Medicare and Medicaid patients could be jeopardized. If a condition of participation is out of compliance, surveyors may determine that the continued operation of the facility could be a threat to patient safety. Thus, hospitals have policies and procedures or medical staff rules that help to ensure that medical records are completed promptly. As most practitioners know, some medical staffs and hospitals are stricter than others in the enforcement of medical record delinquencies.
Many hospitals and other institutional providers are accredited by the Joint Commission, a national health care accrediting organization. Under federal law, if a hospital is accredited by the Joint Commission, it enjoys “deemed status” with the Medicare program. While the Medicare program is required to perform a certain percentage of validation surveys to confirm that the Joint Commission is doing its job in reviewing, evaluating, and accrediting hospitals, most hospitals rely on the Joint Commission for accreditation and deemed status with the Medicare program.
To obtain accreditation from the Joint Commission, hospitals must comply with the Hospital Accreditation Standards, criteria similar to the Medicare conditions of participation. Surveyors for the Joint Commission, prior to the opening of a facility and approximately every three years thereafter, appear on the doorsteps of accredited hospitals and survey the facilities for compliance with a multitude of patient safety, treatment, and administrative requirements.
Timely documentation in the medical record is an important standard in the Joint Commission accreditation process. “Elements of performance” are used by surveyors to judge compliance with various standards. A Joint Commission standard governing timely documentation in the medical record requires an accredited hospital to have a written policy mandating the timely entry of information into the medical record. The hospital must define the time frame for completion of the medical record, which cannot exceed 30 days after the patient’s discharge. The hospital must implement its policy and audit medical records at the hospital. Specifically, one element of performance requires the hospital to measure its medical record delinquency rate at regular intervals, but at least every three months. An unacceptable delinquency rate can result in a hospital’s loss of Joint Commission accreditation. Loss of accreditation generally results in loss of Medicare and Medicaid certification. Without those credentials, a hospital cannot survive.
To obtain and maintain their licensure, Texas hospitals must also comply with laws and regulations relating to medical records. Texas law requires a medical history and physical examination to be placed in a patient’s medical record within 24 hours after admission. Texas law also requires the inclusion of the final diagnosis and completion of medical records within 30 calendar days following discharge.
Good patient care requires the timely completion of medical records. Unless contemporaneous documentation is included in a patient’s chart, it is unlikely that the chart will reflect what the practitioner knew and the treatment that was provided on the day that he saw and evaluated the patient. Patient care errors can occur if medical records are incomplete when additional care is provided. It is not surprising that the National Practitioner Data Bank has taken the position that it has taken.
At the present time, most hospitals give practitioners a number of warnings concerning incomplete records before any adverse action is taken. Generally, the delinquent practitioner is given the opportunity to come into compliance with the medical record completion requirements by completing his charts prior to the passage of 31 days. In light of the new Data Bank clarification, hospitals are evaluating their medical record delinquency and suspension policies to determine if reports must be made to the Data Bank. Physicians who are delinquent or who have a tendency to procrastinate may want to evaluate their own medical record completion activities and consider immediate behavior modification.