Physiatry Practice Management Resources

There has long been a strong relationship between good documentation and a reduction in patient errors, as well as the possibility of a professional liability claim. Problems occur by events as basic as a nurse being unable to decipher handwriting or one partner unable to read a colleague's notes. In the managed care environment, it has become critical to document significant decisions, such as whether or not a hospital admission is indicated or whether a diagnostic test is medically necessary.

If there is a complication or an untoward result, the first thing patients may do is request their records and review the notes. Plaintiffs' attorneys generally represent patients against healthcare providers for economic reasons. Therefore, they are looking at the records with this in mind. These claims are very difficult and expensive to pursue. If, in looking at your records, it appears as if the complaint about information is documented and the patient is noncompliant, the attorney will be less likely to take the claim.

Well-documented records make cases much easier to defend once we get into the courtroom. Jurors have come to expect that important information will be documented. They infer from haphazard records a lack of attention. There is, however, another significant, reason that documentation and documentation systems have become vital-allegations of healthcare fraud. This may be a billing or coding problem, but could also be in a patient care area. Claims have been made that if care was paid for through a prepaid or capitated arrangement, and not provided, fraud has occurred. Further, and perhaps more frightening, is the question as to whether fraud has occurred when there is a claim that the level of care provided does not meet appropriate standards.

Having policies and procedures in effect setting forth the type of documentation required will be key. Making sure your clinical staff is aware of these documentation requirements in advance is also essential. as is making sure that communications over the telephone are documented as a matter of policy or protocol.

Isn't it time for you to start?

Written by: James W. Saxton, JD