Health Information Management

Tip: Spread the word about physician legibility

CDI Strategies, April 14, 2011

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Legible. Complete. Dated, timed, signed, and authenticated. That's what section 482.24 of the Medicare Conditions of Participation requires of medical records. But many facilities struggle to achieve this seemingly simple task. Falling short doesn't just affect quality and patient care. 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 taking a multifaceted approach to reducing illegibility at her hospital. Consider a few of her suggestions:
  • 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. Reisinger worked with her CMO to discuss the issue and brainstorm solutions during her hospital's medical executive committee meetings. For example, they're currently discussing whether to give physicians 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. Reisinger says having one-on-one conversations with physicians can be especially helpful if you use specific examples. 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 is able to have the discussions and has seen how helpful they can be.

Editor’s Note: This article is an excerpt from the April edition of Medical Records Briefing.

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