What flaws are the Recovery Audit Contractors searching for in records?
Illegible documentation, incomplete documentation, unidentified providers, wrong dates of service – and evidence of improper corrections.
To help offices stay safe, the government has set out guides for making corrections so the records pass muster with the RACs.
Those same guides will also ensure the records pass muster with a jury should they end
The definition of correct
For both paper and electronic records, the government says, three principles have to be followed.
• First, the new information has to identify itself for what it is – an amendment, a correction, or a delayed entry. And the identification itself has to be a permanent part of the record.
• Second, the entry has to be signed and dated by the person who makes it.
• And third, the record has to show both the original entry and the clarification or correction.
With paper records, there needs to be a single line drawn through the changed entry so it’s still readable. And whoever makes the change has to sign and date the strike-through.
With EHRs, there needs to be a straightforward narrative stating that an error has been made and is being corrected, also signed and dated. And along with that:
• The new entry has to be flagged to show that it is a change.
•It has to tell where the original entry appears. That’s necessary, because the corrected entry could appear in a different location from the original entry.
• The EHR system has to be able to suppress errors but at the same time make them accessible.
• Any printed copies of an altered record have to identify the new entry as a correction or addition.
Beyond the RACs to malpractice
Beyond the RAC issue, improper corrections are fuel to the fire in malpractice claims, says David H. Krause, a medical malpractice attorney with Seaman Garson in Cleveland, OH.
From a malpractice defense standpoint, the greatest danger is that a correction will be seen as a blatant effort “to cut off the record trail.”
But there is also a gray area where there’s an innocent alteration, and that’s where offices need to be careful.
An example is the situation where a staffer is preparing a record copy in response to a request, checks to make sure everything is there, and in the process makes a change or two to improve the record’s appearance. The change may be nothing more than a dotted I or a crossed t, but that’s enough to cast doubt on the entire record.
All a plaintiff’s attorney has to say is “we know the office went back on this date and made these changes” and the clear implication is that other changes were made as well.
The attorney’s starting point
In a legal matter, the presumption is that the record has not been altered. It’s up to the plaintiff to show that it has.
So what does a plaintiff’s attorney look for?
“The starting point is the times the record has been accessed, “ Krause says. And what many offices fail to realize is that with electronic records, every access gets noted even is the documentation isn’t touched. There’s always a trail of who’s been into the record and when.
From there, the attorney looks at what has happened to the record since the incident occurred- what’s been added or taken out r changed.
Money from the doctor’s pocket
The greatest danger in a malpractice claim is not so much the medical mistake, Krause says. A defense attorney can deal with bad facts. But what an attorney can’t always get around is evidence that somebody tried to cover up those facts.
“If a patient suffers and there’s an indication that the record has been monkeyed with,” the doctor is open to punitive damages. And in most states, record cover-ups are not protected by malpractice insurance. The physician is personally liable.
The problem can worsen. The responsibility can expand to the point that “everybody is in the soup together.” He gives the example of a nurse’s entering information under the doctor’s name. The doctor could be responsible for allowing the nurse to do that, and if the information entered is outside the nurse’s scope of practice, the nurse is also facing trouble.
Making an attorney-safe correction
Changing the record depends on the system, he says. But the safest way to put in a correction or late entry is to identify it for what it is and also identify the original entry it refers to.
Along with that, explain why the entry is late, perhaps that the information didn’t come in until the time of the addition.
When the documentation is honest and changes are clearly identified, there’s nothing to worry about. “If it’s out in the open, nobody can be criticized for altering the record.”
But when the correction or addition isn’t clear, watch out. If the last day of treatment was in October, the patient died in December, and then in June there’s a not-so-clear record change, eyebrows go up.
Put the onus on the vendor
Krause also gives a word of safety advice, and it is to follow the EHR program’s instructions for making corrections.
“Follow them to a T,” he says. The vendor has to verify that the system complies with EHR requirements, so if the office follows the vendor’s recommended procedures and a mishap happens, it’s the vendor who has to answer to it.
