June 2016

Unfinished Business
By Susan Chapman
For The Record
Vol. 28 No. 6 P. 18

Findings from The Joint Commission show many surveyed hospitals house incomplete medical records.

When so many aspects of health care revolve around quality documentation, it would be good to know that providers are accomplished medical record custodians. Depending on your perspective, the news on that front isn't half bad. But in large part, that isn't good.

As part of its 2015 accreditation process, The Joint Commission, which accredits and certifies nearly 21,000 health care organizations and programs, found that 49% of surveyed hospitals did not meet all the requirements necessary to maintain complete and accurate medical records for individual patients.

According to The Joint Commission's "Record of Care, Treatment, and Services" chapter in the Comprehensive Accreditation Manual for Hospitals, health care organizations must meet 10 elements of performance to maintain complete and accurate records, each of which are evaluated during a survey. Among the requirements are that the clinical record contains information to support the patient's diagnosis and condition, as well as justification of the treatment, care, and services; and it properly documents the patient's outcomes.

Sheila Guston, CHDS, AHDI-F, supervisor of HIM document integrity at Spectrum Health and president-elect of the Association for Healthcare Documentation Integrity, is not surprised at The Joint Commission's survey results. "My understanding is that this does not even take into account the accuracy of the actual content of the health care documentation, which is where we are seriously lacking in quality standards. Unfortunately, this will only get worse as more and more clinicians are required to create their own documentation," she says.

A Waiting Game
One of the most common documentation errors made by health care organizations has to do with procuring practitioner signatures and the date and time of documentation. This is a particular concern at facilities using paper records or a combination of paper and electronic.

Charmaine Vinton, RHIT, CCS, CPC, director of risk management/HIM at Brattleboro Memorial Hospital, a 61-bed, not-for-profit community hospital in southeastern Vermont, says securing physician signatures in a timely fashion is the facility's most pressing documentation issue. "Due to the nature of our records system [a hybrid of paper and electronic], in terms of incomplete charts, it is a challenge having physicians sign the chart," she says. "Sometimes, for instance, the chart will be reviewed by the CDI [clinical documentation improvement] team, and it takes longer than we would like for the doctor to sign off."

At Brattleboro Memorial, although there is little delay between dictation and transcription, once the chart is transcribed, physicians must sign the paper record. Like those charts that have been sent for review, garnering those signatures expeditiously can become a challenge.

"Dates, times, and signatures have historically been a problem for all institutions," says Lanette Morgan BSN, RN, BC, director of health informatics at Fremont Health Medical Center in Nebraska. "Now, the EMR automates many of these functions. Although we have less of a problem with signatures, if a physician handwrites a progress note, for example, he can still forget to enter required information like the time."

John Wallin, MS, RN, associate director of standards interpretation at The Joint Commission, says dating and timing are the two elements of performance most frequently scored as noncompliant. "The main reason for this is actually simple: Dating and timing are easily found by surveyors in record review," he explains. "They may be looking for other information, but they incidentally also notice that the author of the entry did not date and/or time it. These elements are required by CMS [Centers for Medicare & Medicaid Services] and, because a number of our standards are cross-walked to the CMS Conditions of Participation, they stand out to us. In organizations where they are still on the paper record, or in a hybrid environment, is where we commonly see entries that are not dated or timed."

Wallin says these errors are mostly due to forgetfulness. "Also, sometimes it's difficult—especially for physicians—to understand why and how these seemingly small tasks can impact patient care," he says. "It is important because it helps tell the story of patient contact during the care process. It gives an accurate timetable of when something was ordered and when orders are implemented. It establishes a baseline for future care and a timeline of events. Additionally, dating and timing establish a historical record of past events.

"Another challenge to dating and timing entries in the medical record is how we actually define an entry in a medical record," Wallin continues. "For instance, a nurse can accept a telephone order. He or she will enter date/time, the name of the practitioner, the nurse who took the order, and the signature. Now, the practitioner is required to authenticate that order, essentially confirming it. In this situation, it might be a day or two after the order was received before this happens."

In that scenario, The Joint Commission considers the physician's signature to be a separate entry into the medical record that must be dated and timed because it is different from the time the nurse made the initial entry. "Two entries, the order and then the follow-up confirmation from the physician, require individual dating and timing for each," Wallin says.

Some organizations have taken steps to help practitioners understand the value of dating and entering times on patient records. For example, programs have been established in which physicians themselves host presentations on the topic. Wallin says such peer-to-peer education has proven to be effective.

Other Target Areas
Morgan believes that although signing, dating, and timing are critical documentation errors that must be addressed, other factors used to determine incomplete medical records cannot be overlooked. "In order to mark a record as complete within a 30-day time span, an inpatient record must contain a discharge summary," she says. "At times a physician may be waiting for all preparations to be finalized before dictating or completing the discharge summary. When everything is finalized, the physician may not be able to complete the documentation for a variety of reasons and completions are delayed."

Besides a failure to produce a timely discharge summary, the requirement to chart a history and physical within 24 hours often gets overlooked due to time pressures associated with patient care, Morgan says.

Supporting the patient's diagnosis in the documentation is a particular focus of Joint Commission surveyors. "A patient is admitted with abdominal pain. We could be administering pain meds, doing a scan, etc, but something that would not be consistent could show itself in the record," Wallin says. "For example, we took an X-ray of the patient's foot. Why? Nowhere in the record is the need for that test indicated, and it does not support the initial complaint of abdominal pain. Therefore, those types of entries may be questioned."

Justifying care comes under similar scrutiny. Like the example of a patient with abdominal pain receiving a foot X-ray, care not in line with the complaint will be questioned. "Or, we ordered pain medications, and they were administered. Is nursing assessing and reassessing pain? The record needs to indicate why pain meds were administered in this case," Wallin says.

At organizations still working with paper records, legibility issues can be a concern. "If a surveyor cannot read the note, we will ask a nurse to find out what the chart says," Wallin says. "If no one can read the entry in a record, we say this information is not sufficient to support care."

Legibility can create a potential for risk. "If the writing is illegible, we might mix up medications that sound alike," Wallin says. "A doctor could order two medications that sound alike, but if they're not clear, risk is created as to which medication we are giving. For example, there are many different kinds of insulin. If we can't read the exact type, we create the risk of giving the wrong meds or the wrong dose."

Speech Patterns
Poor dictation habits can play havoc with the accuracy of medical records, with transcriptionists citing enunciation as a particular challenge. "In our hospital, we will have traveling doctors," says Jennifer Blomgren, a manager of medical information at Brattleboro Memorial. "With different accents and English as a second language, it can be difficult to understand diagnoses and meds, for example, and then you've got to get clarification."

Morgan offers a slightly different view. "Most of the time when I see poor documentation, it's the content, not the dictation, that is the problem," she says. "Providers may hold a lot of detailed information in their heads but not articulate it into the record. Sometimes the basic terms used in the documentation aren't specific enough to adequately represent the patient's severity of illness or risk of mortality. Potentially, someone could dictate only a few of the required items, but I still believe dictation itself is not the problem. It's the content."

Consequences
The Joint Commission is one organization that a facility can choose to receive accreditation on behalf of CMS. For hospitals that are not Joint Commission accredited or certified, the survey results are generally informational. However, for health care enterprises striving for Joint Commission recognition or aiming to maintain their status, the organization's findings are a far more serious matter.

"Based on areas of noncompliance, The Joint Commission would require submission of corrective action or potentially notify CMS, which could possibly result in taking away your accreditation and thus impact your CMS-deemed status," Morgan explains. "If you lose your deemed status, you could lose your payment from Medicare, and that would be devastating for most hospitals. Most of the time, it doesn't get that far. More commonly, evidence of standards compliance is required for the hospital."

Morgan says that while The Joint Commission can be lenient in some areas, it can be stricter in others—usually those that directly impact patient care. "When a facility is found to be noncompliant, it must create an action plan and show evidence of compliance within a defined time period," she says. "The Joint Commission has to approve the action plan and the facility has to complete the steps noted in the plan and submit the results of ongoing monitoring of the standard."

"It is imperative that CMS, [The] Joint Commission, and other regulating bodies also have quality expectations for the content of health care documentation," Guston says. "By using health care documentation specialists—formerly medical transcriptionists—as auditors of clinician-created documentation, facilities demonstrate their commitment to quality and safety when it comes to their patients and their providers."

A Call for Quality Control
At Spectrum Health in Michigan, medical record management has evolved. "We have grown from being HIM transcription to being HIM transcription/document integrity," Guston says. "As providers increasingly began creating their own documentation, it was clear that a quality assessment program would be critical to ensuring patient safety and provider protection. Now, in addition to traditional dictation and transcription services, we also audit those documents created by providers themselves within the EHR."

Guston's team reviews all provider-created HIM documents for both critical and noncritical errors. Critical errors, which are defined as those that have the potential to impact patient care/safety, are corrected immediately. "We track those as well as other critical and noncritical errors that may not necessarily compromise patient care or safety but still compromise the integrity of the documentation," Guston says. "By doing this, we identify providers who are struggling and provide training or reeducation as needed."

Even seemingly inconsequential errors can have long-lasting effects, Guston says. "Excessive typos, misspellings, and other minor errors may not sound problematic, but at Spectrum Health they've seen single documents contain upward of 75 misspelled words and typos. With patients accessing their records via portals, compromised documentation will cause them to lose confidence in the providers they entrust their care to," she says. "Providers' opinions of their peers are also damaged when documentation lacks professionalism."

Guston says taking the onus of compliant documentation away from physicians is a sound strategy. "Providers are simply not documentation specialists. We need them to focus on providing top-notch care, and leave top-notch documentation to the health care documentation specialists," she says. "Investing in a quality assurance program such as the one at Spectrum Health is truly a win-win situation for everyone."

Emergency Care Specialists, which employs the emergency department providers at Spectrum Health, has enlisted scribes to help with documentation. Guston believes that documentation specialists, with their mastery of medical terms and EHR functionality, would be better suited for that task. However, she concedes that providers do appreciate having scribes available.

"While these new documentation methods go a long way in the ability to gather large amounts of data, we are missing a critical component: the patient's story," Guston says. "Through traditional transcription and use of back-end speech recognition, the patient's story was told, but now it's all about data elements. That story, the piece that is so critical to patient care, is now missing and lost amidst templates and drop-down fields. The Joint Commission standards are about quality, including the patient narrative, and I can't emphasize enough that documentation must meet that high bar. Quality is critical to the providers, the facilities, and especially to patient care."

— Susan Chapman is a freelance writer based in Los Angeles.