Federal regulations for nursing facilities allow for the use of rubber stamp signatures by physicians provided that the facility authorizes their use and has a statement on file indicating that the physician is the owner of the stamp and attested that they will be the only one using the signature stamp F386. See section on late entries, addendum, and clarifications. Patients seen at the emergency department have the following information included in their records: time and mode of arrival, disposition and condition upon conclusion of treatment in the emergency department, discharge instructions, whether the patient left without being seen or against medical advice, and a statement that a copy of the record is available to the practitioner responsible for follow-up care. If physicians don't sign the reports in two days, discontinue the service. If a new sheet was started, the lines available on the previous page must be crossed off.
For example, a treatment that can be delivered any time during a shift, could have a block of time identified on the treatment record with staff signing that they delivered the treatment during that shift. When double-sided forms are used, the resident name and number should be on both sides since information is often copied and must be identifiable to the resident. The correction must indicate the reason for the correction, and the correction entry must be dated and signed by the person making the revision. The menus for charting are consistent for all types of data entry. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.
Determine what method works for each one and use it. The tools themselves are not considered part of the legal medical record. Specificity In writing entries use language that is specific rather than vague or generalized. The ink should be permanent no erasable or water-soluble ink should be used. Any discussions of advance directives will be incorporated into the patient's clinical record.
With each update of the master signature legend there should be a date indicating implementation and revision. Completing all Fields Some of the questions or fields on documentation tools such as assessments, flow sheets, checklist documents may not be applicable to the resident. Delayed entries within a reasonable time frame 24 to 48 hours are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service. Public health records and statistical reports. Because the labels lose their adhesiveness over time, facilities must select a vendor and labels that offer a guarantee on the length of time the labels will retain their adhesiveness.
Ownership, Responsibility and Security of Medical Records A. Hospital policy requires that every medical record entry is dated, identifies the author, and authenticated when necessary. For example, all paper forms are required to have the patient label in the top, right-hand corner and the name of the organization in the top left. Documents with multiple sections or completed by multiple individuals should include a signature area on the document for all applicable staff to sign and date. Surveyors look to medical records documentation in open records more and more frequently as evidence that the hospital carries out its policies and procedures in many clinical and administrative areas, including patient rights, patient education, leadership, and the medical staff.
Authenticating Documents with Multiple Sections or Completed by Multiple Individuals Some documentation tools particularly assessments are set up to be completed by multiple staff members at different times. Although not a requirement, using a pocket folder could help to contain any labels that may have become dislodged from the backing sheet over time. Make sure entry is complete and contains all significant information. The organization conducts record review at the point of service using predetermined, defined measures that consider consistency, clarity, timeliness, accuracy, legibility, quality, and presence of all requirements. Proper error correction procedures should be used for the entry.
Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. From a reimbursement perspective, some fiscal intermediaries have local policies prohibiting the use of rubber stamp signatures in the medical record even though federal regulation allows for their use. Cloning also occurs when medical documentation is exactly the same from patient to patient. Hospital policy establishes time requirements for various elements of the record. Editor's note: The above article was adapted from the book Ongoing Records Review: A Guide to The Joint Commission Compliance and Best Practice, Fifth Edition, written by Jean S.
Coders responsible for reviewing documentation should be cognizant of providers who demonstrate patterns of insufficient documentation that necessitate addenda. Medical record information identifies the patient, supports the diagnosis, justifies the treatment and services, documents the course and result of care, and promotes continuity of care. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary. Read on for 15 tips to improve documentation at your facility. At a minimum, the electronic signature must include the full name and either the credentials of the author or a unique identifier, and the date and time signed. Then, as staff review records for completion, they signal missing items by the color unique to the physician responsible. Certain communication tools are part of workflow and are not maintained after patient's discharge.
This is not an easy topic and there is no way to give one answer that will apply to the many scenarios that coders may encounter. Medical record addenda must be properly identified and reference must be made to the original note being amended. Correspondence concerning requests for records. These corrections or additions must be dated, preferably timed, and legibly signed or initialed. Is it meaningful and appropriate to the encounter? Do not let emotions show up in charting.
Compliance with the policies is monitored through ongoing record review. When a pertinent entry was missed or not written in a timely manner, the author must meet the following requirements: 1. Hospital policy stipulates when countersignatures are needed for entries made by nonindependent practitioners. If the documentation will be reported by exception e. . It may contain information, which is privileged and confidential. Medical record addenda should be an exception, rather than a routine or recurring part of medical record documentation.