Excerpt: Spread the word about physician legibility
CDI Strategies, May 26, 2011
Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!
Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the Medicare Conditions of Participation requires of your medical records.
But many hospitals struggle to achieve compliance in this area. And falling short doesn't just affect quality and patient care. Consider the financial effects; auditors can deny claims when orders are missing signatures or documentation is illegible. Consider that, per the March 10, 2010, CMS Transmittal 327, "If the signature is missing from an order, [auditors] shall disregard the order during the review of the claim."
Patti Reisinger, RHIT, CCS, HIM director at Community Medical Center in Missoula, MT, is making an effort to increase compliance with signature and legibility requirements, especially in light of the recent audit activity she has seen on these issues. The hospital has also recently undergone a few Comprehensive Error Rate Testing (CERT) audits for missing lab signatures.
Reisinger is taking a multifaceted approach to reducing illegibility at her hospital. Consider a few of her suggestions within your CDI department:
- Spread the word through a physician newsletter. Reisinger submitted examples to the hospital's physician/clinician newsletter regarding legibility. The newsletter was well received, says Reisinger.
- Get your chief medical officer (CMO) involved. “Work with your chief medical officer to deliver your message to the medical staff committee,” Reisinger says. She worked with her CMO to brainstorm solutions and discussed whether to give additional physicians printed rubber stamps with their names to clarify signatures, or asking-though not yet insisting-that physicians print their name underneath their signatures.
- Take a one-on-one approach. Use specific examples of poor penmanship and sloppy documentation during one-on-one conversations with physicians, Reisinger says. It may not be possible to meet individually with all clinicians at larger facilities and organizations, but because Community Medical Center is a smaller hospital, she conducted the conversations and knows how helpful they are.
- Track progress. At Community Medical Center, each inpatient nursing department conducts regular audits legibility and signature compliance. Each department reviews approximately five records per week, Reisinger says.
Editor’s Note: This article was originally published in the HCPro Inc., newsletter Medical Records Briefing.
Want to receive articles like this one in your inbox? Subscribe to CDI Strategies!
Related Products
Most Popular
- Articles
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Catch up on what's new with injections and infusions
- Topic: CMS, OESS post new security compliance review information, checklist
- Capturing all necessary codes for IUD insertion and removal can be challenging
- HIPAA Q&A: Level of encryption needed for email
- What does case-mix index mean to you?
- QA:Coding multiple initial infusions
- News and briefs: Oklahoma Osteopathic Association against residency bill change
- OB services: Coding inside and outside of the package
- E-mailed
-
- Q/A: Volume requirement for reporting hydration services
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- HIPAA Q&A: Level of encryption needed for email
- CMS has reformulated payments for some bilateral procedures
- Catch up on what's new with injections and infusions
- New conflicts of interest create new challenges
- Q&A: Follow CMS' coding guidelines when using modifier -25
- Q/A. One injection code or two?
- What does case-mix index mean to you?
- ED-to-inpatient transfers are flawed with safety gaps
- Searched