Health Information Management

Excerpt: Spread the word about physician legibility

CDI Strategies, May 26, 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 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.

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