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Compliance Hot Topics: Billing and Coding, EMTALA, Stark, HIPAA

Question of the Week

Welcome to Compliance Monitor Q&A.

Our mission is to answer your difficult compliance questions—and your simple ones, too. To submit a question, send it to Compliance Monitor Q & A editor Kate Alvarez at kalvarez@hcpro.com. We hope you enjoy this service and we welcome your feedback.

This week's questions

• Should a patient's name be on each page of the medical record?
• Do physicians' orders have an expiration date?

• Sharpen registration process for better reimbursement

• How does your organization handle patient financial issues?

Q: Should a patient's name be on every page of the medical record? In particular, if an organization uses a tri-fold record, is there a law requiring the patient's name on every page? I realize that this is best practice, but what are the legal requirements?

A: In today's ever-changing health care system, facilities keep medical records in a variety of formats including paper-based, computerized, and electronic records. The multiple governing bodies, such as Centers for Medicare and Medicaid Services, National Committee for Quality Assurance, Joint Commission on the Accreditation of Healthcare Organizations, and private insurance companies, that audit medical records do require the patients name be documented correctly, but they don't expressly state that it should be on each page. And although the federal government also has not issued any laws or guidelines requiring the patient's name on each page, it is proper, from an ethical business perspective, to do so.

The American Health Information Management Association (AHIMA) created a legal medical record task force that has issued guidance regarding legal documentation standards. The standards have mainly applied to a paper medical record, but most are also applicable to documentation in other types of medical records as well. AHIMA points out that there isn't a one-size-fits-all definition for the legal record because applicable laws and regulations vary by practice setting and by state.

From a legal standpoint, it is wise for every page in the medical record or computerized record screen to be attributable to a patient by first and last name and medical record number. Double-sided forms or pullout forms should have the patients name and number on both sides because information is often copied and must be clearly identifiable to any reviewer. Forms, both paper and computer generated, with multiple pages must also have the patients name and number on all pages. In addition to consulting AHIMA's excellent legal guidelines, check for individual state requirements. Remember, it is healthcare professionals' duty to respect the right of the patient to be accurately represented in the medical record.

This question answered by Kelly Brink, CCS-P, CPC, a leader of nationwide coding and compliance seminars for ICD-9-CM, CPT-4, compliance, outpatient surgery and radiological imaging. Ms. Brink is currently a compliance consultant for a multi-hospital system.

Ever wonder how Kelleen Brink started answering questions for Compliance Monitor Q&A? Well, you too can help your peers with their compliance issues! Just Click here or see the information below.

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WE NEED YOUR EXPERTISE!

Join the Compliance Monitor Team! Compliance Monitor Q&A relies upon experts just like you to answer pressing compliance questions. We're looking for experts in coding, billing, documentation, HIPAA, EMTALA, Stark, laboratories, and many other areas of compliance.

If you are interested in answering questions from your peers, please e-mail Compliance Monitor editor Kate Alvarez.

AVOID BILLING FRAUD AND ABUSE AND GET ACCURATE REIMBURSEMENT FOR SERVICES RELATED TO YOUR CLINICAL TRIALS

Attend the 90-minute live audioconference, "Medicare Coverage for Clinical Trials: How to comply and get full reimbursement." Designed for billing and finance professionals, compliance officers, investigators, and research coordinators, this program will use case studies to help you apply the billing regulations to real-life situations and implementation challenges. This program will be held on Friday, November 21, 2003.

To register, or learn more, CLICK HERE or call 800/650-6787. Be sure to mention source code EZ23159B.

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Click here to take our quick survey on your financial policies and procedures.

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To find out more on how to cut down on denials and other billing headaches, order the pay-per-view article "Sharpen registration process for better reimbursement." The cost is $10. Subscribers to the online version of Briefings on Coding Compliance Strategies have free access to this article. Subscribers to the print edition can find it in their October issues.

A $30 steal.
You can read this article and much more in the October issue of Briefings on Coding Compliance Strategies. Your cost: Five stories for only $30. You'll also learn how there may be partners for improved documentation right on your units, how your outpatient coders could be utilized for inpatient coding, the answers to four questions for better coding compliance, and how to follow the twists and turns of hernias to the right code.

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Don't take discharge planning compliance lightly

Discharging patients isn't as simple as sending them out the door. There are regulatory and legal risks involved. Join us for an live 90-minute audioconference and get tips for reducing delay days and better managing length of stay; how to manage the ever challenging 'patient choice' issue; communicating with the chief financial officer and compliance officer, and learn how to improve the discharge process, from assessment to documentation.

We're saving a seat for you at "Discharge Planning Compliance: Strategies to Overcome Regulatory and Legal Risks" on Monday, November 24 beginning at 1 p.m. Eastern.

To register or to learn more, CLICK HERE or call our Customer Service Team at 800-650-6787. Please mention source code EZ23261B when you call.

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A: To read the answer to this question, click here.

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To submit your answer, go to the Question of the Week at Complianceinfo.com.

Here are the answers to the last survey:

When will your organization begin auditing its HIPAA compliance program?

• Within the next six months: 68%
• In 7 to 12 months: 17%
• In 12+ months: 9%
• We do not plan to audit: 6%

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Network with your audit colleagues

"Audit Talk" is a new, moderated chat forum that members can use to post messages or questions for their peers 24-hours-a-day. "Audit Talk" offers a free forum to network, share ideas, and solve problems for those in the audit industry. Getting involved is easy. To subscribe, just send your request to this e-mail: owner-audit_talk@hcpro.com.

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Send your comments and questions about Compliance Monitor Q&A to:

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com