Question

Analyze the case study below. Based best practices from the Integrity of the Medical Records article apply appropriate techniques to ensure the integrity of the record to solve the problem in the case study below.

While Patient A was a patient at Medical Center A, a number of medical tests and diagnostic evaluations were performed in an outpatient clinic over a two-week period. Concern arose about the health plan claim, so Patient A requested a copy of his medical records along with the bill for services. The statement included evaluation and management codes consistently reported at the highest level of service (level 5). Because Patient A is a retired auditor for health plans, he examined the documentation and discovered that the medical history was pulled through within departments, between departments, and in subsequent visits with the same provider using the electronic health record (EHR) system, even when the visits did not include the clinician taking a history. The health plan was billed for a high level of service (of history) for each hospital outpatient clinic visit. Patient A is concerned that the EHR does not have the functionality (or it is not used) to show that the history (or any documentation component) obtained during a previous encounter was copied and reused as documentation for subsequent visits to support physician intensity of service. After many attempts to have services billed at the correct level (what Patient A insists is really a level 2 or 3 evaluation and management when the pulled through data are not considered for service intensity), he contacts the fraud division of the health plan about his concerns.

Answer 1

The duocumentation is a legal part of healthcare which need to be very conciously maintained and anytime that could be used fir any legal cases. Most of the time the medical practitioners have a very casual attitude to maintain the record, so most of the time that is a kind of copy paste job of the previous one. The medical history also become the problem of not having a detailed record. The problem could be solved by making awareness among medical practitioner regarding appropriate maintenance of record. The quality department can keep an eye over them and can start taking new initiative for them to maintain the EHR,that can be done by regular internal audit of data,finding the faulty one,giving some token to the good one etc.An appropeiate data maintenance not only be useful for medical claim but be an indicator for hospital quality improvement.