Accurate record-keeping is an essential component of high-quality healthcare. From medication management to treatment planning and beyond, patient records serve as a critical source of information for healthcare providers as they work to deliver safe and effective care. However, maintaining accurate records is not always easy.
Healthcare providers must navigate complex legal and ethical regulations, keep up with ever-changing medical information, and manage a growing volume of patient data. In this post, Jonathan Lanesky, Healthcare Compliance Attorney, and Daniel Bitman, Regional Vice President with Privia Health, offer valuable insight as to why documentation integrity is so important, the consequences of inaccurate electronic medical records, the importance of maintaining healthcare compliance standards throughout your practice, and tips that can be used for comprehensive, up-to-date, and virtually error-free patient records.
Healthcare compliance refers to the adherence to laws, regulations, and ethical standards in the healthcare industry to ensure patient safety, data privacy, and overall regulatory compliance. This is especially important for electronic medical records as the consequences healthcare professionals face for not following healthcare compliance guidelines can be severe.
Healthcare compliance encompasses several key areas that healthcare providers must address to ensure adherence to legal and ethical standards. The three main areas of healthcare compliance are regulatory compliance, privacy and security, and billing and coding compliance. Regulatory compliance involves following laws and regulations governing electronic health records, while privacy and security focus on safeguarding patient information within the electronic record system. Documentation integrity emphasizes the accurate and complete recording of patient data, treatments, and outcomes, ensuring the integrity and reliability of electronic health records.
Compliance management plays a vital role in healthcare, establishing a robust framework to ensure adherence to laws, regulations, and ethical standards. It involves developing and implementing policies, procedures, and controls to monitor and mitigate compliance risks. Additionally, compliance management oversees training, audits, and investigations to identify areas of non-compliance and implements corrective actions. By fostering a culture of ethical conduct and accountability, compliance management promotes a strong foundation for maintaining accuracy in electronic health records. If done right, proper compliance management can keep all healthcare professionals in your practice safe from the watchful eyes of the federal government.
Jonathan explains that “medical records are crucial for avoiding legal problems because they are the main evidence of the interaction between the doctor and the patient.” He encourages his clients to make sure their notes include the four components, also referred to as “SOAP.”
In healthcare, “SOAP” notes are a structured method of documentation used by healthcare providers to ensure comprehensive and standardized medical record-keeping. Each letter in “SOAP” represents a specific component that contributes to a well-documented patient encounter.
These four components, Jonathan explains, ensure specific documentation for each visit, which is complemented by Daniel’s affirmation that “specificity is everything”.
Daniel goes on to explain that accurate documentation ensures that every provider has access to the same information about a patient’s care. Not only does this enable a thorough understanding of the patient’s medical, prescription, and treatment history, but it opens the door to more informed decisions being made as to new diagnosis.
While EMR systems have alleviated many issues related to incomplete records, they also have their limitations. Jonathan states that users of many EMR systems often “check whatever boxes they need to, to get paid, without justifying the visit”. This creates an issue as progress notes may not properly show the provider’s medical decision making, which could result in withheld reimbursements.
Jonathan also warns of the heavy reliance on copy and paste within progress notes, especially as insurance companies move toward the use of artificial intelligence (“AI”) programs. Based on his experience, Jonathan notes that providers often copy and paste progress notes, and then only add a short update at the end about the recent visit. He suspects that AI will be tasked with flagging seemingly identical progress notes, causing insurance companies to withhold or deny coverage, which is why he pushes providers to revert to SOAP for thorough notes.
To ensure accurate and complete documentation, Daniel explains that to keep patient records accurate and thorough, Privia uses AI programs to “check patient cases and clinical documents for any overlooked details”. This can include completion of patient claimed history, confirming the annual update of certain diagnoses, or anything that can play a role in the patient’s medical care. Being able to pinpoint any gaps encourages providers to be intentional in their notetaking so that their decision-making plan is laid out in a concise manner.
When performing routine quality audits of your practice leads to the discovery of inconsistencies or discrepancies, Jonathan warns providers not to let it linger. Knowing of discrepancies, and not taking corrective action, can land you and your practice in a range of legal issues.
Jonathan warns that a practice could be audited by the state Attorney General, CMS, the federal government, or even insurance companies because of inaccurate patient records. If you fail to correct known discrepancies, you could lose federal program billing privileges, get slapped with a federal indictment containing accusations of fraud, or be served with a lawsuit claiming negligence.
It is crucial for providers and practices to comply with federal and state-specific laws regarding accurate record-keeping. Failing to do so can lead to regulatory issues, such as license revocation, and impact proper reimbursement.
In addition to the legal and regulatory implications, inaccurate patient records can have significant effects on patient care and safety. Miscommunication, incorrect diagnoses, improper treatment decisions, and compromised patient safety can all result from inaccurate or incomplete records. Furthermore, poor patient records can negatively impact reimbursement, healthcare quality assessments, and overall patient satisfaction.
To avoid these consequences, healthcare providers must prioritize accuracy in maintaining patient records. This involves ensuring the completeness, correctness, and timeliness of documentation, as well as adhering to established guidelines and best practices.
With the constantly changing legislation surrounding the healthcare industry, how can you be sure that your practice is meeting the regulatory and compliance requirements for documentation? By having a conversation with a healthcare law attorney like those in Chapman Law Group’s Compliance team. Our attorneys can provide a hands-on audit of your practice to reveal issues that may leave you susceptible to government intervention. Contact our office to learn more about how we can work on getting your practice on the right track.
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