Health Information Management

Tips for Joint Commission EPs 19 and 11

HIM-HIPAA Insider, September 10, 2012

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Timing and dating all entries in the medical record can be difficult if the medical record is still in paper form or is part paper and part electronic. The recent CoP change to no longer require authentication of verbal and telephone orders within 48 hours will definitely help. However, every entry must still be signed, dated, and timed, and surveyors are looking hard at this issue as it is resulting in 66% noncompliance! This has been an uphill battle for years, but HIM can help.

Tips for compliance: Impose stiff penalties for noncompliance. This will mean implementing a concurrent review of medical records to identify the offenders, ­provide accurate data to leadership, and take action when staff is not compliant. This review should not be limited to physicians! Anyone who documents should be held responsible for compliance.
Continue to drill home the importance of dating and timing entries through newsletters, posters, email blasts, and other means of communication.
Showcase those who do it right. Everyone likes to be praised for doing a good job. Consider a staff challenge between documenters, or perhaps give away a "golden pen/electronic signature" award!
I hate to even mention this one, but tagging entries in the medical record can at least alert caregivers to sign, date, and time!
Stamps are permissible, but they must include signature, time, and date. Guard against different handwriting and ink color, especially for the date and time! Hospitalists are a stellar example of now to use stamps to not only improve signing, dating, and timing, but legibility and identification of the caregiver as well.
This is an excerpt from the September edition of Medical Records Briefing.

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