Computer Charting

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Computers are tools.  They give your staff the ability to surf the net, check FaceBook or even work.  Sometimes, surfing the net would be preferable to the computer documentation I have had to suffer through lately.

This is not a new pet peeve but it is regularly exacerbated.  One idea is to turn off the software’s ability to carry over visit note content from one day to the next.  Agencies are afraid their nurses would quit if they did that.

Just two weeks ago, I wrote a plan of correction for an agency that addressed essentially duplicate notes.  It seems the surveyors are also noticing very little original content in visit notes.  The plan my client decided on was to disable the ability to cut and paste for one week for an initial offense for a nurse, a month for the second and permanently for the third.  This only works if you system allows you to individualize each user’s abilities.

Everyone uses templates and revises old documents and contracts to make new ones.  Everyone’s phone rings and has distractions.  The difference with clinical documentation is that typo’s are the stuff of Medicare Fraud and Abuse.

Do you know Daniel R. Levinson?   He holds the position of Inspector General of the United States.  When someone refers to the OIG, they are referring to his office.  Unless you are paid handsomely to defend someone against charges brought by the OIG or you play tennis with him, you never want to hear your name in the same sentence as Daniel Levinson’s.  So, having said all that about the Inspector General, let’s hear what he has to say about your computer documentation.

Experts in health information technology caution that EHR technology can make it easier to commit fraud. Certain EHR documentation features, if poorly designed or used inappropriately, can result in poor data quality or fraud.

This next one kind of gets under my skin a little but he is absolutely correct.  I just wish he would remember that the most important reason to document is to improve patient care by committing to writing pertinent facts about the patient and their treatment.

When doctors, nurses, or other clinicians copy-paste information but fail
to update it or ensure accuracy, inaccurate information may enter the
patient’s medical record and inappropriate charges may be billed to
patients and third-party health care payers.

The Inspector General highly recommends the use of audit tools, as well.  I’m not sure that is an effective solution to all but the most egregious offenses.  The nurses I know sign their name to duplicative documentation.  I know nurses who share passwords all the time.

The only time that I have ever detected the appearance of actual fraud is when nurses documented more visits than are possible on a single day with over lapping times.    I know from frequent experience that it is easy misdate a handwritten signature or document.  Computers are far more reliable than most humans in getting the date straight.

The best audit tool begins at the hiring process.  People with integrity do not commit fraud.  We have all been desperate for someone to fill an urgent need in the schedule and plugged in the wrong person who had not been vetted properly.   That’s a painful mistake because ultimately, the agency is responsible for what happens inside its organization.

The second best audit tools are the back office people and coders who read scores of documentation.  They will notice duplication and unlikely events sooner than a QA nurse who is reviewing a smaller percentage of clinical records.  Coders and billers spend hours of time at computers each day.  They make scores of errors, correct them and move on to the next plan of care.  When they see an obvious typo, they don’t see it as Medicare fraud because, get this –nobody is actually trying to commit fraud.

The only people who view these typos and occasional duplicated notes as fraud are the ones who can deny you payment or arrest you.  If I were you, I might take a second look at your computer documentation practices.

Just saying…. 

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