Medical chart review is an important process in scenarios such as – when a physician is audited by an insurance company, or when he/she is sued for medical malpractice, or when Medicare conducts a peer review or when the Office of Professional Medical Conduct conducts an investigation. The content and quality of the medical chart is a major factor in all the above circumstances that is taken into consideration to determine if the physician owes money to an insurer, whether he/she is guilty of malpractice, whether he/she will be removed from the Medicare program or whether they will lose their license. Given the importance of accurate and complete medical record documentation to reduce medical errors, improve patient care and stay away from adverse legal outcomes, physicians need to be very attentive in this regard. In the event of a lawsuit, a comprehensive medical record analysis would reveal what the physician did for his/her patient; it is the most important piece of evidence physicians have to defend themselves. In fact, an accurate and complete medical chart is most helpful for the defense attorney because it provides the material to prepare the case and defend the client efficiently.
Let us consider the major stumbling blocks that stand in the way of clear and accurate medical record review.
- Illegible medical charts that make it difficult to understand the details of the services provided – why a certain treatment was provided, or when it was provided and other related details. Such medical records not only deter the medical record reviewer, but could also lead to the physicians themselves and other caregivers to mistake the name of the prescription, the dosage, the date and such other important details.
- Non-contemporaneous medical records that are not allowed in a court of law. Many physicians do not chart each patient promptly and prepare the documentation at a later time, which could lead to incomplete and incorrect medical records.
- No date or signature when new entries are made: It is difficult to identify the clinician who provided the service or interacted with the patient when there is no signature or date entered when changes are made or new entries written.
- Not documenting the year on dates in the medical chart is another major problem. Physicians see patients over a series of years and if the year is not specified in the record entries, it could create confusion.
- Using highlighters and colored pens can have a negative impact and make the medical chart unreliable. Colored inks may become dim with the passage of time and make the documentation unclear. Colored highlighters may block or obscure the text underneath when it is copied. In both these cases, the medical chart may become useless in court to defend the physician. Use of pencil is also not advisable because the plaintiff side might always argue that the record was changed.
- Use of non-standard charting symbols: Physicians sometimes make up their own charting symbols without specifying at the beginning of the chart what the symbol is and what it signifies.
- Use of obscure abbreviations: Use of ambiguous abbreviations can be as problematic as using non-standard charting symbols, making the defense attorney’s work more cumbersome.
- Inaccurate records: Incorrect use of a word or phrase can put the physician in trouble. It is important to take some time and write exactly what the physician means in the records.
- Late additions, amendments and deletions: This is another mistake physicians and other clinicians make – adding, amending or deleting something from the record without specifying why the change was made. It is important to specify that the change was made to increase the accuracy of the chart, and also clearly specify the who, what, when, why, where and how regarding the modification. Absence to do so could lead to a conclusion that the person making the change was doing something illegal.
- Signatures and initials that are not clear: In such instances, it is difficult to identify who must be put on the witness list. It must be easy to identify who signed particular entries.
When the above mentioned flaws are avoided when creating the patient chart, medical chart review becomes easier and more efficient. It lightens the defense lawyers’ work and enables them to prepare and argue the case effectively.