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Three real-life scenarios test your standards of conduct

HIM Connection, February 24, 2004

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TOPIC: Three real-life scenarios test your standards of conduct

Standards of conduct should outline how laws, regulations, guidelines, and accreditation standards guide the way your organization conducts business. They also play a key role in determining what steps an employee should take in the face of noncompliant activities. Use these three real-life scenarios to see how the elements of your standard of conduct would hold up with real-life challenges.

Scenario one: Content, quality, and completeness of documentation

Situation: While reviewing a patient record on the floor for concurrent coding, you notice that the physician has documented a diagnosis of "gram negative pneumonia" on the facesheet. However, there is no evidence in the rest of the documentation to support this diagnosis. What should you do?

Action: At a minimum, bring this lack of documentation to the physician's attention. Explain the need to either change the diagnosis or append the documentation in the patient's record to reflect the actual condition. Depending on your internal policies, report this information to a clinical department or compliance specialist. Document the incident, along with the physician's response, and file it with other relevant compliance documentation. Make a note of it in your compliance monitoring report as well.

Scenario two: Release of information

Situation: One of your patients expired in your facility. The patient's sister arrives at your door to request a copy of his medical record. She explains that she has been appointed as the trustee for the estate and produces a copy of a letter from a local attorney. What should you do?

Action: Explain to the requestor that you can only accept an official document from the probate court appointing her as trustee for her brother's estate. You may not rely on the attorney's letter in this situation.

Scenario three: Record retention and storage

Situation: You see a resident stuffing a patient's record in his backpack on the way out of the department. What should you do?

Action: Confront the resident immediately and explain that under no circumstances are patient records permitted to leave the facility. Cite the applicable standard of conduct and law, if necessary. Request the record and return it to its appropriate loction. Document the entire incident, including the date, time, name of the resident, your name, and the patient record number and name. Give this information to your HIM Compliance manager.

Continue this exercise with your own standards of conduct. Think of examples you can use to test the policies and procedures your employees should follow.

This week's excerpt is from the book, "Seven steps to HIM compliance," by Ruthann Russo, JD, RHIT. To order or learn more, click here.

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com

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