Corporate Compliance

* What can we do about illegible physician handwriting?
* Do we have to give our privacy notice to all of our existing patients?
* Pay-per-view article: The inside scoop: How the OIG's pharma guidance affects providers

Compliance Monitor, February 28, 2003

What can we do about illegible physician handwriting?

Q: As part of our ongoing record review, we are monitoring legibility of handwritten entries in medical records. What would be the appropriate process to follow when addressing legibility of a physician's handwriting? I would like to have some options for corrective action when I approach the medical staff with this issue.

A: Hospitals that allow handwritten notes must develop standards on how to address physician handwriting. Establish a procedure if hospital staff can't read a chart. For example: If legibility problems arise, physicians must be available within a certain time frame to either dictate or re-write a note for clarity.

According to medical documentation guidelines, if a chart note was not documented, the service was not done. That's also true if the chart is illegible and a CMS (Centers for Medicare and Medicaid Services) auditor can't read it. Since a physician's notations in the medical record are an important part of treatment, illegible notes create a serious problem for all health care providers who need the information for follow up care.

Some organizations are switching to electronic medical records (EMR) to avoid these, and other problems, including the legibility issue. EMRs also help to reduce process and patient errors due to illegible or incomplete notes. However, EMRs are expensive and take years to implement.

If workers are repeatedly asking physicians to rewrite notes, hospital administration and/or the applicable medical staff committee should meet with them to review the problem and assess remedies. If, even after education or other corrective action measures, physicians continue to produce illegible medical records, it could be an indication that you have an ineffective compliance program.

Set up a policy so physicians are clear that if they fail to improve their legibility, you could terminate them from the medical staff. This is rare, but you can avoid it through education, collaborative dialogue, and automated resources, like EMR and dictation services.

This question was answered by Michael O'Connell, MHA, CMPE, CHE, senior director of the Cleveland Health Network MSO, LLC, in Independence, OH.



Pay-Per-View Article

The inside scoop: How the OIG's pharma guidance affects providers

The days of drug companies flying physicians to Hawaii for a five-day vacation interrupted only by a one-hour lecture are long gone. But there are certain education programs and physician-sales rep arrangements that could put providers at risk of violating anti-kickback regulations. And the government is watching.

Go to "The inside scoop: How the OIG's pharma guidance affects providers" for the rest of this article. The cost is $10. Subscribers to the online version of Strategies for Health Care Compliance have free access to this article. Subscribers to the print edition can find it in their March issues.

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Do we have to give our privacy notice to all of our existing patients?

Q: As a covered entity under the Health Insurance Portability and Accountability Act (HIPAA), I know that our facility must begin providing a notice of privacy practices to our new admissions starting in April 2003. I know that we need to post it at our facilities and on our Web site. We also need to provide it to anyone who asks for it. But we currently have over 6,000 existing clients. Do we need to make an effort to give the notice to all of them?

A: The HIPAA privacy rule, in part 164.520 (a) - ( c ), as modified on August 14, 2002, requires covered entities like hospitals to provide a Notice of Privacy Practices to any individual with whom the provider has a direct treatment relationship

According to the rule, you must do so "[n]o later than the date of the first service delivery, including service delivered electronically, to such individual after the compliance date for the covered health care provider . . ."

As of April 14, 2003(the day the privacy rule is official),facilities must provide each and every one of its active patients a Notice of Privacy Practices on their first date of service on or following April 14, 2003. Facilities will also have to make a good faith effort to obtain written acknowledgment that each patient has received the notice. If you don't obtain it from your patients, you must at least document your good faith efforts to do so and the reason why the acknowledgment was not obtained.

This question was answered by Monica P. Navarro, Esq., an attorney specializing in regulatory compliance and counseling in health law, with Frank, Stefani, Haron, & Hall in Troy, MI.

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