Beware these 7 charting pitfalls

February 3, 2006

An exaggeration? These case histories prove otherwise—and show you how to avoid the same mistakes.

A good doctor always keeps good records? Right?

Wrong. Quite a few otherwise good doctors don't. And while defending them before the Florida state medical board, I've been surprised to learn how seriously the state reacts to record-keeping violations, even when there's no evidence of negligence or injury to patients. In a review of 600 disciplinary hearings before the board, I found that more than one-third involved medical record infractions.

Most states have specific statutes defining the requirement for medical records, and many state medical boards are adamant in enforcing them. Although the infractions are seldom deliberate attempts to hide the truth, the board may interpret them as efforts to cover up mistakes. A physician may be a good doctor, but if his patient records aren't accurate or complete, there's no way to prove it.

Case 1

Failure to complete hospital records. When an internist stopped admitting patients to a hospital, he didn't bother to complete the charts on 59 of them, despite repeated notices from the hospital. After two years, the hospital finally revoked his staff privileges and reported him to the state medical board.

Although none of the patients was harmed by the incomplete records, the board fined the doctor $2,000 and required him to take 20 CME hours in risk management and record-keeping.

LESSON

Take your hospital's record-keeping requirements as seriously as it does. Hospital staff physicians should complete patient charts immediately after treatment. Hospitals, however, generally allow some leeway. Most set time limits such as 24 hours for admitting notes, 48 hours for surgical procedures, and 15 days after discharge for completion of the records. The main reason for the limits: Third parties won't pay without complete records.

Case 2

Delay in writing admitting notes. During a busy holiday weekend, a psychiatrist admitted three patients on an emergency basis. She wrote extensive orders including some potent psychiatric medications, but didn't write or dictate admitting notes until several weeks later. When the hospital discovered the lapse, it reported her to the state board because its bylaws require admitting notes to be entered within 24 hours. Although the psychiatrist's notes were accurate, they were entered too late to justify the patients' courses of treatment-a violation of state regulations.

The board fined her $2,500 and ordered her to take five CME credits in risk management and record-keeping.

LESSON

State regulations recognize that sound medical judgment requires prompt documentation.

Case 3

Right patient, wrong surgery. A gynecologist filed an insurance claim for a total abdominal hysterectomy when, in fact, he'd performed only a right salpingo-oophorectomy. The state board, notified by the hospital, charged him with failing to maintain adequate records, practicing below the acceptable standard of care, and filing a false report.

At an informal hearing, the physician explained that he'd dictated his OR note several days after the procedure and mistakenly described another patient's surgery. The board believed his account and dismissed the false-claim charge. But for the other two charges it fined him $2,000 and required his hospital to file periodic reports listing the dates he performed surgery and the dates he completed his OR notes.

LESSON

Dictate notes on procedures while your memory is fresh.

Case 4

Alteration of medical records. An ENT specialist performed a biopsy on a woman with a mass in her throat that turned out to be a benign thyroglossal cyst. Claiming partial disability of her tongue, the patient sued for malpractice. The doctor settled, but the case was reported to and reviewed by the state medical board.