Medical Records Alert

WellStar has an ongoing review processes to evaluate compliance with standards such as The Joint Commission and Medicare.  Recent reviews have identified instances where Medical Staff members are not in compliance with these standards and, in turn, have had inappropriate medical record documentation.  We want to make sure every Medical Staff Member is aware of the applicable CMS/Medicare Conditions of Participation, State Rules and Regulations for Hospital Licensure and The Joint Commission Standards requirements for medical record documentation to allow those Medical Staff members out of compliance to immediately correct this.  Click "Read more>>" to view the requirements.

The requirements include the following:

1. A history and physical shall be recorded within the first 24 hours of admission to inpatient services and prior to the performance of any procedure.

2. If a history and physical has been performed within 30 days prior to the Patient’s admission, a legible copy may be used provided it is updated, dated, timed and authenticated within 24 hours prior to procedure.

3. An operative progress note shall be entered into the medical record immediately after surgery to provide pertinent information for use by any individual who is required to attend the patient and transfer the patient to the next level of care. The operative progress note should include pre and postoperative diagnoses, procedure performed, surgeon’s name, anesthesia findings, blood loss and condition.

Some things not to do in the medical record include the following:

• Completing an operative note in advance of completion of surgery. 
  
  • For instance, providing an operative note that has been completed with estimates of blood loss and declaration of no complications that has been signed with the date of the surgery but faxed or submitted in advance of the surgery itself is absolutely not within appropriate standards for medical record documentation.
    
    • Of note, it is certainly acceptable to have an operative note template that provides the required elements to be completed as a “checklist” that is then used postoperatively with completion occurring postoperatively rather than preoperatively.
• Dating a preoperative history and physical on a day different than the date the history and physical was completed.
  
  • For instance, dating a history and physical (H&P) as occurring on the day of surgery when the history and physical was completed within the acceptable 30-day window is not acceptable.  It is acceptable to complete an H&P within 30 days, date it on the actual date the H & P occurred and then within 24 hours prior to surgery, you provide an update of that H & P. The update note is then dated on the actual date that you completed the update.

Remember, as a WellStar Medical Staff member, you are required to abide by all applicable Medical Staff Bylaws, policies, rules and regulations, as well as state and federal laws. If you would like to review the CMS Conditions of Participation and The Joint Commission Standards documents, contact kenneth.kunze@wellstar.org.

Although it is difficult changing habits, our concern is both patient safety and ensuring compliance with state and federal laws and regulations. Again, if you are failing to comply with the standards, please correct this immediately.  Remember, persistent deviation from or failure to comply with medical record documentation requirements is not consistent with the expected behavior of Medical Staff Members and is grounds for further review and corrective action.

In addition, state law prohibits any knowingly made misleading, deceptive, untrue or fraudulent representations in the practice of medicine or in any document connected therewith.  The Composite Board of Medical Examiners is responsible for reviewing these concerns and can suspend or revoke a physician’s license or refuse allow re-licensure on these grounds.

Thank you in advance for your cooperation in efforts in providing the best quality of care to your patients.  If you have any questions, please feel free to contact Kenneth Kunze, M.D., SVP & CMO at 770-792-5018.