Facing challenges in documenting medical care

Every healthcare professional knows that, at some point in their medical practice, they may be called on to defend patient care. When time passes and our ability to accurately recall information is diminished we should be able to rely on documentation of events to answer questions. There are practices you can adopt that can make it easier to make a good habit of properly documenting everything that happens before, during and after patient care.

Documenting everything is not the only key component to keeping proper records. Your medical record entries must be adequate representations of what happened. Imagine a jury reviewing records in a medical malpractice case, assume they do not spend much of their time reading medical records. How might they react to inadequate records? What may be obvious to you may not be to them. When others are charged with judging your credibility, the quality of your medical records can either enhance or diminish your credibility.

Examples of detrimental documentation practices, as identified in the recently article published by The Doctors Company, The Faintest Ink.[i]

  • Gaps and delays in documentation
  • Illegible entries
  • Dictation with blanks
  • Unflattering or judgmental patient descriptions
  • Entries appearing to vent negative feelings
  • Altered records and records missing documents or entries

To ensure proper documentation, each time and every time, the best practice is to develop a system for entering and recording information. Almost like a checklist, you can determine the rules and procedures for managing information. Identify details regarding when, where, how, what and why information is recorded. While it may seem like extra work, at some point your medical records could be under review and read in isolation of other information. Therefore, every single time it is helpful to identify why an entry is being recorded.

Features and benefits of good documentation habits

Increased communication with patients and increased continuity of care should increase understanding, decrease misunderstanding. In many medical malpractice cases, the root of the problem leading to a complaint can often be identified as failure in the communication process.

One way to improve communication is to use dictation equipment to make your patient notes. When you dictate notes right in front of patients you are more likely to read the details into the notes so that the patient can understand everything. If, on the other hand, you are making dictation and sound cryptic or unclear, a patient could become nervous and worried about not having a clear understanding of their doctor visit.

When making entries, beware of the easy mistakes that you can make when using forms and templates. A simple mistake in recording information on a form can cause problems. If there is an error in checking boxes on one form, could there be more errors on other forms? Making independent notes every time you record patient information better insures accuracy and credibility of information.

It is a good idea to audit and review medical records to ensure that documentation procedures are consistently used. In the audit process, a reviewer may detect entries that may require a second look. If there is an error or missing information, it is always best to make a new record and attach it as an addendum to the original. Do not change or alter records when there is active or pending litigation.

For more tips on documenting patient medical records or if you have questions about exposure and liability in the event of a patient complaint or claim for malpractice, please be in touch with Michael V. Favia and Associates, P.C.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] Source for article summary: The Doctors Company, The Faintest Ink, By Carol Murray, RHIA, CPHRM, Patient Safety/Risk Manager II.

Relaxed restrictions: Health care licenses and criminal convictions

On January 1, 2017, new laws on the books in Illinois took effect. Among the new laws passed was a bill to protect applicants for professional licenses who may also have a record of a criminal offense and conviction. Prior to the new law, applicants for health care licenses[i] were barred from applying for a professional health care license if they had been convicted of criminal offenses.

In fact, a 2011 law, now rescinded, had automatically and permanently revoked or denied licenses to certain health care professionals with certain past felony convictions. Imagine working in a health care career for years and being stripped of your license to work and earn a living. Those affected by the 2011 law may now move forward in applying for the reissue of their health care license.

Those previously stripped of licenses may seek relief:

New health care license applicants who may have been precluded from receiving a license prior to January 1 may now request the issuance of a health care license by the State of Illinois. The Illinois Department of Financial Regulation (IDFPR), who issues and regulates health care licenses and professionals, may no longer deny a request for a professional license solely on an applicant’s criminal record unless the conviction is directly related to the occupation for which the individual seeks a license.

“The new measure is part of ongoing efforts by Governor Rauner and legislators to remove unnecessary barriers to the professional licensure while ensuring the health, safety, and welfare of the public.[ii]

New opportunities for independent review:

Under the law, if an individual applies for a license to work in regulated health care position, and they have a criminal conviction, the individual may qualify for special review under the new law. The Petition for Review, timely filed, can be used to affirmatively establish that the individual has been rehabilitated from their conviction.

There are several factors to be considered by the IDFPR in reviewing Petitions for Review, such as the seriousness of the underlying criminal conviction, any prior disciplinary history associated with the applicant, and notably, the individual’s voluntary remedial actions. Remedial actions can help establish an individual accepting responsibility for an error, and when coupled with rehabilitation, the decreased chances of future errant actions.

Child support obligations:

The new rule also gives the IDFPR more discretion in disciplining a license holder who falls behind in child support obligation. While it may be true that some child support obligors knowingly fail to pay child support, others may fall behind unintentionally. When the health care worker is denied their license to earn a living, and they want to be current on their support obligation, taking their income away can further complicate the problem.

If you believe the new law applies to your health care career and opportunity to hold the proper license, whether you were previously denied, suspended or revoked, you should know that every situation is fact-specific and what applies to some may not apply to others. Call Michael V. Favia & Associates, P.C. for a comprehensive review of your professional licensing matter to learn if the new law may change your health care career outlook.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

 

[i] Note: Health care workers include doctors, nurses, social workers, pharmacists, and more.

[ii] IDFPR Press Release Dated 12/29/2016, A Pathway to Licensure: Changes to Law for Health Care Workers with Criminal Convictions.

Preventing medical malpractice claims with smart strategies

Physicians and their patients all make their best efforts to exchange information to ensure great patient care. At points in the healthcare process, there can be mistakes leading to dissatisfied patients. In many cases, miscommunication and errors can be corrected with little harm done. In other instances, malpractice complaints are filed. Everyone involved in the patient care process would prefer to avoid a negative incident or malpractice complaint. Being diligent in assuring good patient care involves adopting strategies in reducing risks of medical mistake.

In a recent article published in Medical Economics, several doctors and healthcare professionals shared their perspectives on improving patient care, communication and documentation, ideally reducing malpractice lawsuits.[i]

The following is a summary of 5 strategies to reduce malpractice lawsuit threats:

Proper documentation means documenting everything

“Every doctor is taught that if you didn’t put it in the chart, you didn’t do it.[ii]” In error in noting a patient’s chart begs the question of how to correct the typo or wrong word choices. The best practice is to make a separate notation which you identify and incorporate by reference in the original notation. Changing or deleting an error can lead to trouble.

Noting everything in the patient’s chart should also include any communication with patients and family members. Ask them to explain the information back to you to make sure they understand. Make a note in the chart describing exactly how the communication took place. If you note everything with the sense that any other physician could step into patient care without missing a beat, you are engaging in a positive habit that should help avoid medical mistakes and malpractice claims.

Transparency with patients and facilitating access to charts and notes

Does your physician share access to notes and charts? Would you know how to read and interpret those notes if they were made available to you as a patient? Transparency in healthcare services allows patients and their physicians to all understand the reason and course of care. A patient may elect to seek another medical opinion and if they do, the more information you share with them as the primary physician, the better you may be protected from later claims of medical mistake or malpractice. It may take longer to create notes that others can understand, but the benefit in transparency and documentation makes this a best practice.

Expressing empathy when sharing information with patients

When a physician discovers a medical error, they may face tough decisions in communicating errors with patients and their families. While the natural inclination may to apologize and express remorse for a medical mistake, too many physicians are worried about an admission of error which could lead to a malpractice claim. While contrition may be, appropriate and appease concerned patients and families in many instances, there may be times your apology is insufficient to resolve dissatisfaction.

Illinois is one of many states with “sorry laws” protecting physicians from exposure in malpractice cases for expressing apologies and remorse to patients and families. The form of an apology should be sincere and honest. You can effectively express empathy without saying too much that may confuse or give the patient and family the wrong idea. Apologies when due, can be an appropriate best practice. Notwithstanding, being aware of hospital administration and policies that may affect your patient communications is important.

Managing the risks associated with electronic health records

The intended purpose of electronic health records (EHRs) is to solve information and documentation concerns. The portability and access to EHRs should help prevent medical mistakes and malpractice claims. Nevertheless, there are EHR pitfalls to avoid, such as using auto-populating fields in the forms and copying and pasting. Drop down menu errors can also be a problem and cause the wrong information to be populated in the EHRs, which can lead to medical mistakes and malpractice. Imagine another physician relies on wrong information in a patient’s EHRs and misses a drug allergy or gives a patient wrong dose of medications.

Maintaining positive relationships with patients and their family

Reducing uncertainty and increasing understanding is good for physician-patient communication and care. When family members are involved, it is a good practice to let them know what is happening in the care process and what issues may arise and affect the patient’s health. Showing the patient and their family attention and explanation of what is happen and what is anticipated in patient care may give the patient and family solace in knowing their concerns are important and well-attended. Being realistic and transparent is always a best practice to increase understanding and prevent medical mistakes and malpractice claims.

Adding these strategies to your practice

Since so much documentation is required in healthcare, it should be reasonably simple to include these proactive patient care strategies to any healthcare practice. Adding reminders to engage in these tasks is helpful in adopting them as positive habits in practice. Health law, litigation and licensing attorney, Michael V. Favia works with patients, physicians and healthcare organizations to identify and manage risks and to prevent and resolve conflicts when they arise. An audit of a physicians practice can lead to solutions in preventing malpractice.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] Medical Economics, 5 strategies to reduce malpractice lawsuit threats, By Liz Seegert, Nov. 10, 2016.

[ii] See HNi above.

PODCAST: An overview of current and future osteopathic medicine with Dr. Karen Nichols

Today’s podcast interview with Dr. Karen Nichols, focuses on osteopathic medicine and how osteopaths are different from traditional medical doctors. In the next 30 minutes Karen will talk to us about the whole person approach to osteopathic medicine, treatment and care. Learn about the rise of awareness and practice of osteopathic medicine and what we may anticipate in the future of comprehensive holistic healthcare. Use this link to listen anytime.

Topics covered in this 30-minute interview:

  • Similarities and differences between MDs and osteopathic physicians
  • A rise in the osteopathic profession and an increase in women osteopaths
  • The Institute of Medicine of Chicago and its role in osteopathic medicine
  • Career opportunities in, and the future of osteopathic medicine

Karen J. Nichols, DO, MA, MACOI, CS is the Dean of the Midwestern University/Chicago College of Osteopathic Medicine. Prior to serving as Dean, she was Assistant Dean, Post Doctoral Education and Division Director (chair), Internal Medicine at the Midwestern University/Arizona College of Osteopathic Medicine. Dr. Nichols a graduate of the Kansas City University College of Osteopathic Medicine (KCU-COM) with a DO degree and an Honorary Doctorate of Humane Letters. She has a Masters degree in Management with a specialty in Healthcare Administration from Central Michigan University. Dr. Nichols served as president of the American Osteopathic Association, president of the Arizona Osteopathic Medical Association and president of the American College of Osteopathic Internists. She is presently on the board of the Osteopathic International Alliance.

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Michael V. Favia & Associates are available to advise and represent health care professionals and the general Chicagoland community with a variety of legal issues. With offices conveniently located in the Chicago Loop, Northwest side and suburbs, you can schedule a discrete meeting with an attorney at your convenience and discretion.

For more about Michael V. Favia & Associates’ professional licensing work, please call (773) 631-4580, visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You may also connect with Attorney Michael V. Favia on LinkedIn and on Avvo.com where you may also read client endorsements and reviews.

PODCAST: Medical office management tips with Donna Weinstock

Today’s podcast interview with Donna Weinstock, from Office Management Solution, a Chicago area provider of solutions and services for medical offices, focuses on current trends and topics in medical practice management. In the next 30 minutes, Donna will talk to us about her approach to running a business and healthcare practice and offer examples of opportunities in improving our operations, patient service and employee retention. Click/tap here to listen to the interview anytime.

Topics covered in this 30-minute interview:

  • Why medical offices need policy manuals;
  • How to best divide and delegate tasks;
  • Making smart choices when recruiting employees;
  • When it makes sense to use outsource solutions;
  • Services provided by Office Management Solution.

Donna Weinstock is president of Office Management Solution. She has spent over 30 years in healthcare, first working in physician offices as a biller and receptionist and later as a practice manager.

This has allowed her to truly understand the workings and day to day operations of healthcare practices which now allows her to help her clients/physician practices to become more efficient and therefore more profitable.

Donna is a is a speaker and writes for healthcare magazines.

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Michael V. Favia & Associates are available to advise and represent health care professionals and the general Chicagoland community with a variety of legal issues. With offices conveniently located in the Chicago Loop, Northwest side and suburbs, you can schedule a discrete meeting with an attorney at your convenience and discretion.

For more about Michael V. Favia & Associates’ professional licensing work, please call (773) 631-4580, visit www.IL-Licensing.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You may also connect with Attorney Michael V. Favia on LinkedIn and on Avvo.com where you may also read client endorsements and reviews.

Brian Clauss, Director JMLS Veterans Clinic, speaks to ISBA Health Care Section Council

The Illinois State Bar Association Health Care Section Council welcomed Brian Clauss, Director of The John Marshall Law School Veterans Clinic at its council meeting on November 18. The Veterans Legal Support Center & Clinic provides free legal assistance when a veteran has been improperly denied benefits by the Veterans Benefits Administration.

Clauss shared how the clinic and its volunteers are successful in assisting veterans with disability claims. He also informed the Council about opportunities for lawyers who want to volunteer and get involved with the clinic. This VA benefit appeals clinic, one of the first of its kind in the U.S., is a nationally recognized pro bono program. In addition to helping veterans with their benefit appeals, the clinic also shares news and resources with veterans who may take advantage of a variety of benefits made available to them in local communities.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

New Rules: CMS overhaul, must comply to participate in Medicare and Medicaid

There is big news in the overhaul for nursing home condition standards. Last month, “the Center for Medicare and Medicaid Services (CMS) published a final rule to revise the requirements that Long-Term Care facilities must meet to participate in the Medicare and Medicaid programs.[i]

The Law Firm of Michael V. Favia & Associates, P.C., works with nursing home directors, administrators and staff to address regulation and compliance matters. We are happy to help nursing home health care professionals with any questions about these new rules.

The last overhaul of nursing home regulations by CMS was done in 1991 and since that time there have been significant advances in patient care and the services available in senior healthcare. The article published by JD Supra Business Advisor is worth reviewing.

Here is a list of the topics covered in the CMS final rule:

  1. Resident Abuse, Neglect and Exploitation;
  2. Admission, Transfer and Discharge Rights;
  3. Resident Assessments;
  4. Comprehensive Person-Centered Care Planning;
  5. Discharge Planning Process;
  6. Quality of Care Requirements;
  7. Quality of Life;
  8. Physician Services;
  9. Nursing Services;
  10. Behavioral Health Services;
  11. Pharmacy Services;
  12. Dental Services;
  13. Food and Nutrition Services;
  14. Facility-Wide Assessment Requirement;
  15. Binding Arbitration Agreements;
  16. Quality Assurance and Performance Improvement (QAPI);
  17. Infection Control;
  18. Compliance and Ethics Program;
  19. Physical Environment; and
  20. Training Requirements.

“CMS states that the revisions to nursing home regulations are intended to reflect the substantial advances that have been made in the theory and practice of service delivery and safety.[ii]

Nursing home administrators and educators will be busy working on how they can help everyone who works in nursing homes learn the new rules and regulations. Procedures and protocols will need to be developed to ensure nursing homes comply with the CMS rules or otherwise risk losing the privilege of participating in the Medicare and Medicaid billing programs.

About us: Michael V. Favia & Associates, P.C. is a health law and litigation firm in Chicago representing individuals, healthcare professionals and organizations with civil legal matters as well as professional licensing and regulation.

Chicago health law and litigation attorney Michael V. Favia and his associates in several locations and disciplines, advise and represent private individuals as well as healthcare professionals in all types of litigation and administrative matters involving licensing and regulatory agencies.

Michael V. Favia and Associates, P.C. represents individual physicians and health care organizations in the Chicago area with a variety of legal matters. With offices conveniently located in the Chicago Loop, Northwest side and suburban meeting locations, you can schedule a discrete meeting with an attorney at your convenience and discretion. Michael V. Favia & Associates is available at (773) 631-4580. Please visit www.favialawfirm.com and feel free to “Like” the firm on Facebook and “Follow” the firm on Twitter. You can also review endorsements and recommendations for Michael V. Favia on his Avvo.com profile and on LinkedIn.

 

[i] JD Supra Business Advisor, CMS Releases the First Comprehensive Overhaul of Nursing Home Conditions of Participation in Over 25 Years. By John Sisher II, Nov. 3, 2016.

[ii] See HNi above.