Are you thinking about writing a romance novel? Or posting something nasty on-line, maybe in response to this post? Well, feel free to remain anonymous. But, the medical record is no place to hide your identity. All entries into the medical record should be dated and signed.
Of course, you say. Everyone knows that.
Using an Electronic Health Record (EHR) can allow more than one health care professional to document in a single note. A medical assistant may document the History of the Present Illness, (HPI) and the physician may just accept it or sign off on it. (Not allowed: only the billing provider may document the HPI.) A student may document a note, and the supervising clinician may then edit the note and sign off on it. A Physician Assistant may start a note, document the majority of the note and the physician edits it, and signs off on it. What is the problem? The medical assistant, student or PA is not signing off on the portion of the note that he or she has documented. Reading the note on line (without looking at an audit trail) or looking at printed version of the note, it may not be clear who has documented what.
All entries into the medical record should be dated and signed. Oh, did I say that already?
How does an auditor know? An experienced auditor will note inconsistencies, changes in spelling and punctuation and the evidence of co-signature statements. More importantly, the EHR should leave an audit trail.
Recently, a report by the Office of the Inspector General has validated and emphasized this. The OIG released two reports related to this topic recently. The first (Not all recommended fraud safeguards have been implemented in hospital EHR technology) wasn’t as sexy (barely a candidate for anonymous) as the second (CMS and its contractors have adopted few program integrity practices to address vulnerabilities in EHRs), which described copy/paste and over-documentation. The New York Times reported on the second of these. But the first contained very specific statements about the authorship of entries into the medical record and audit functions. Here are a few of the OIG recommendations. If you haven’t read the report, take the time to do it. (Search OIG OEI-01-11-00570)
Proxy authorship: Requires that the user ID of the original author be tracked when an EHR update is entered “on behalf’ of another author. (I.e., distinguish between entries made by an assistant and a provider.)
Provider identification: Requires the use of a provider’s NPI to restrict EHR access and track updates to EHRs by author.
That is: every entry into the EHR should be verifiable. Who documented that portion of the note, who edited it later, who signed off on it. Later, I’ll address the issue of copy and paste and over documentation that both of these reports target. But for now, be sure that every entry into the medical record is signed by the author. If multiple staff members and professionals are entering data into the medical record, be sure that the author’s identity is clear. Your EHR should track these entries so that your internal or external auditor can verify authorship.
And really, “Written by Anonymous” is so 19th century.