By Stuart E. Hoffman, DC, FICA
Every conscientious practitioner is constantly looking for ways and means to strengthen and enhance every dimension of their clinic’s operations. This is inherent in our obligations to the public as direct access, doctor-levelprofessi0onals and it also makes sound, responsible business sense. As we look for positive, proactive steps doctors of chiropractic can take to put their practice on a more reliable, defensible footing, documentation and record keeping are still at the top of the list. Record keeping and the thorough documentation of care decisions is an area that is not always given the attention it should receive because of the tedious nature of that activity, the inclination to postpone such work and competing demands for the doctor’s time. In this new era of audits and challenges to even the most basic clinical procedures, you will always be well served, however, by making good records a priority, both current and old files, since they are the basis on which you will need to rely to explain and perhaps defend all of your care decisions.
There is a growing national focus on record keeping and documentation, and no where is this more intense than in the Medicare program, where a high-profile campaign led by the US Department of Health and Human Services’ Office of the Inspector General has targeted chiropractic documentation issues. The Medicare situation, escalating battles with third-party payment agencies over “necessity” and other issues, and a new interest on the part of state regulatory boards in upping the record keeping requirements are all signs of things to come as far as patient record demands.
Good records are your best defense in all contested arenas, from third-party payment claims processing to, heaven forbid, malpractice claims. On the other side of the equation, inadequate records are the major reason doctors have claims rejected or disputed, regardless of the necessity for the care given, the validity of the procedures applied or the wishes and needs of the patient.
Now is the perfect time to examine your office procedures and to see how you can strengthen and enhance your patient records efforts. It is a basic responsibility as a doctor-level professional, and the right thing to do for your patient. You will also be making a positive and proactive contribution toward meeting a new wave of scrutiny and record keeping demands which all practices will be confronting in the coming months.
High-quality files start with a personal commitment. Then, maintaining complete, accurate, well-organized and timely records is mostly a matter of work, and the implementation of a sound system which is understood by staff and supported to the greatest degree possible by emerging technologies.
It is vital from the outset to distinguish at all times between billing and collections records and patient care files. The two should be kept separate at all times, with no exceptions. Billing and collections issues, even as marginal notes, should never be entered into clinical files. Missed appointments can and should be recorded for what they are to the clinical record: missed appointments. Remember, patients have access to everything in their files, and so do their attorneys, third-party payment agencies responsible for covering their care, and state regulatory boards. None of these parties need to be confused or concerned that financial issues have or might ever have a bearing on the provision of care.
You can begin by asking ten key questions, and then acting on the answers. Here, common sense, knowledge of the formal rules and requirements in your jurisdiction, and the operational demands of the major third-party payment agencies with which you interact are your main guideposts. Also, it is important to remember that record keeping is a marathon endeavor, requiring steady, on-going effort and attention to detail, which cannot be rushed, and will likely require some extended period of time to implement change.
What are the official rules? Official regulatory boards all have adopted specific rules on record keeping. Most state or provincial boards have those rules readily available on official websites and you should read and understand, as well as download those rules and maintain a paper file as to those requirements. Periodically check for changes. This is your baseline set of requirements.
There are also emerging legal issues that you need to track and act upon according to the laws in your jurisdiction regarding authentication of electronically stored records and “electronic signatures”. How will a court in your jurisdiction, for example, view a completely electronic record, signed electronically? While this should not be an issue at all, states in the US are only slowly adopting changes to the laws governing health care and other records systems that recognize the validity of an electronic signature. Any vendor seeking to sell a records program should be able to provide written and referenced information on such emerging rules and questions. If they cannot, buyer beware!
What are my documentation goals? The first and fundamental objective of patient records is to collect accurate, timely and relevant factual data on the status of the patient, to record chiropractic procedures, both diagnostic and care delivery, and to note measures of progress. The State of New York’s Office of Professions, in a chiropractic practice alert, offered the following advice on record keeping basics:
Health care professionals must maintain proper documentation that accurately reflects the evaluation and treatment of the patient, consistent with the appropriate levels of care. Clinical notes serve several important purposes including:
- ensuring comprehensive and consistent patient care
- improving communication with other professionals
- facilitating reimbursement from insurance carriers
- helping to protect licensees against litigation
- standardizing clinical documentation in support of research.
As a competent and prudent practitioner, the initial entry in a patient record should ordinarily include a comprehensive case history documenting an examination of symptoms, past history, family history, past surgeries, traumas, and previous and current medication. You should maintain thorough and accurate records and notes that reflect your care, treatment and interaction with each patient.
This is sound, reasonable advice. New practitioners may want to spend some time developing a documentation template, a written description and list of what the model patient record should contain. Facts should be the entire focus, not speculation, opinions or irrelevant observations. You need, however, to expand your thinking about what should be in the record to include data on patient non-compliance, missed appointments, lack of follow-through on exercise or other advice, noting the instructions you gave the patient and your rationale. Also, document all referrals you may have made to other healthcare professionals.
Patient records are legal documents. They represent the provider’s basic pre- and post-care responsibility, and whatever form they are filed, must be kept in unaltered form and be clearly authenticated by the creator.
What is my system? The physical means of recording and storing patient data can be as simple as a filing cabinet or as complicated as the most sophisticated electronic, computer based records program. Whatever the system, it must facilitate the efficient, timely and complete collection and storage of patient information, in an orderly and accessible format. The place to begin is to establish a basic information format, whether using patient records software or paper forms, and prepare a written outline of the practice’s record keeping policies and procedures. Once you have your protocol for records data collection and storage, make sure that everyone involved in the clinic process understands what their responsibilities are in relation to the records plan, and what only the doctor can and must do. Clear lines of responsibility on record keeping and a daily review of the status of files is your best guarantee that you will be able to maintain the optimal files you should be maintaining.
Does my system meet my needs? What your patient records should contain, who puts it there, and your obligations to be timely in their maintenance are usually fairly clear and obvious issues. How your system works, especially in terms of the time and effort they require, may take additional careful thought and study. The hand-writing of notes and marking of forms may work well in some instances, and in others, be a back-breaker that holds the process back, cutting into time that could better be spent seeing patients. Ultimately, this question will lead to a quest for mechanisms to streamline the entry or patient data. There are multiple vendors and records systems available in today’s chiropractic marketplace. Shop critically and carefully. There are no magic programs or systems that will do the work for you, but you can pre-address common questions, develop check-lists and templates that can make things easier and quicker to record. You must, however, be on the lookout for cutting of corners by staff or even associates, and always be conscious of your own responsibilities.
How is patient data stored? This question deals with accessibility and ease in placing new data on file, and retrieving patient files for use in the on-going evaluation and care of patients. The physical layout of the clinic, where the computer terminals and/or filing cabinets and writing surfaces are placed, where blank forms are stored, etc., are all elements to look at and adjust to make the process flow with the greatest possible efficiency. How you array your clinic geography, how you position your staff and which staff have what tasks can make the system flow well. Also, how much time each recording task takes needs to be observed and measured according to some efficiency standard.
Does the staff understand and support the documentation and records system? First, a clear, practical and above all, written records keeping protocol is the best foundation for making sure your staff understands the system. Also, the doctor cannot assume that even the best employee will simply pick up how things are supposed to work. Training time to make sure your staff understands the records system and their personal responsibilities therein is vital to the success and smooth operation of the practice. Periodic reviews of how the process is working, looking at all aspects of the records function, from the order in which they should be kept to the timely nature of required entries, are a must.
Are records secure? In addition to accessibility, patient records systems must address the vital issue security. Are they locked in a secure place, secure from tampering, theft and damage from fire or other disasters? The doctor has a unique personal responsibility to provide for security of patient records, both from the point of view of the patient, where doctor patient relations are and must remain confidential, and from a concern for accuracy. Patient records must be under the strict control of the provider to ensure that no one has the means to remove, add or amend any data without your instruction, knowledge and approval.
Electronic health records (EHR) transmission and storage represent a new frontier for security. Computers have become the target of a host of threats, from inadvertent systems failures to hostile viruses, and even outright data theft. Multiple access points over an open network like the Internet dramatically increases the possibility of patient data being compromised. This is, in part, because of the large numbers of people who have access to such data. According to a well-documented article in The Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient’s records during a hospitalization, and 600,000 payers, providers and other entities that handle providers’ billing data have some access. This is just the number of people who are supposed to have access, and does not take into account those who should NOT have access, but who are seeking to corrupt, exploit or steal confidential data.
Electronic records require completely dependable back up copies, best stored off-site in a bank safe deposit box or comparable secure location, regularly updated virus and hacking fire walls, reliable computer hardware and software, and an appropriately trained and supervised staff. With all the demands and risks, it is no wonder that health care, especially private practice doctors, have been slow to convert to electronic records systems. According to a recent federal government study, “The healthcare industry is among the least automated industries in the nation. Studies have estimated that the healthcare industry as a whole is almost 20 years behind the rest of the nation’s industries. Limitations in software, hardware and networking technologies have made EMR difficult to affordably implement in small, budget-conscience and multi-location healthcare organizations. Smaller doctor’s offices (1-10 physicians) have been the slowest adopters of Electronic Medical Records.”
According to a post on www.mbahealth.com which appeared on April 1, 2009, most individual practitioners appear to be initially overwhelmed by the issues and choices related to electronic records programs. They lay out the issues and challenges pretty well in a single paragraph, and also gave some still very sound advice on where to look:
“If you aren’t familiar with health information technology, good luck acclimating to the ever-changing and complicated environment. There are over 300 EHR/PM vendors out there and 95% of them are NOT right for you. You can also expect a good number of those vendors to be acquired, go out of business, or not be able to support you in a way that works for you. Right now the safe bet is to start on http://www.cchit.org/, which is the only EHR certification board out there, and look at which vendors are certified.”
Security also applies to how you dispose of patient records. Disposal must be done through shredding or supervised destruction so that no unauthorized person might find them in the trash. In fact, one of the few major HIPAA enforcement actions on record was against a doctor who simply dumped several years worth of old files in trash containers behind a retail complex a mile or so from their clinic, to be found by the spouse of one of the patients whose record was included in those dumped. Don’t do that!
Am I HIPAA compliant? Federal regulations require much greater control over the storage and distribution of information in patient records. The HIPAA law (Health Insurance Portability and Accountability Act) established very detailed requirements in this area. The first and only comprehensive federal privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers took effect on April 14, 2003. Developed by the US Department of Health and Human Services (HHS), these standards provide patients with access to their health care records and more control over how their personal health information is used and disclosed. The regulation covers health plans, health care clearinghouses, and those health care providers who conduct certain financial and administrative transactions (e.g., enrollment, billing and eligibility verification) electronically. All doctors of chiropractic in the United States are covered under this law.
Every doctor of chiropractic should have a written HIPAA compliance plan that is understood by all parties involved in the practice. Your HIPAA plan need not be complex or voluminous. It should, however, outline office security measures, identify which employees and under what circumstances those employees have access to those records, and how patient consent to address simple and practical things like sign-in sheets, appointment reminders and even billing are established. The good news is that your patients can consent to do things they way you want to operate in your practice. Your obligation, however, is to get that consent on file. ICA has a model form that has been widely distributed among the membership, and is still available upon request.
The HHS has repeatedly stated that that it is not the intention of the regulations to disrupt quality care, normal clinic operations or to restrict communications between doctor and patient. Key to chiropractic concerns is the role patient consent will play in the administration and enforcement of the rules. Simple patient consent steps can address such normal chiropractic procedures as sign-in sheets, referral activities, patient testimonials and other public associations with patients. At the same time, common sense controls and restrictions to health records will certainly be required and adjustments to some clinic procedures relating to records may be necessary in some practices.
For an update on HIPAA, see federal documents available on-line at http://www.hhs.gov/ocr/hipaa/ .
What do my colleagues do and how do I stack up by comparison? You do not need to make your records decisions in isolation. One of the best reality checks is simply to ask colleagues you trust how and what they do, and devote some time in observing several practices’ actual records processes. Younger practitioners can benefit greatly from the learning-by-doing that older colleagues have experienced, and fellow ICA members have a long and positive tradition of helping each other out. This will always be time well spent, especially if you are considering investing substantial amounts in computerized records systems and programs.
Where can I go for help? First, no practitioner should be shy about asking for help, seeking advice or looking at various models to see what works best for other practices. At the center of all considerations, however, must be the formal requirements for records as established by your jurisdiction’s chiropractic regulatory board, HIPAA rules and any other statutes, rules or obligations unique to your area. Once you know what the rules are, your state, provincial or national associations are great resources. ICA is there for you and has a powerful record of member service. Also, your malpractice carrier is a logical source of advice. ChiroSecure is always there to serve ICA members and policy holders and to answer your questions on records, liability and other potentially troublesome or problematic issues.
There are a number of additional key points to keep in mind. Most are just common sense, but we all need occasional reminders, even about what should be obvious.
First, remember that you, the practitioner, are the owner of all patient records and have control over their disposition. Patients may request copies and in most instances you have an obligation to provide those copies, including copies of x-rays. You also may have the ability to charge for those copies. You should always maintain a full record of who has received copies or summaries of those records and any such information should always be consistent down to the smallest detail with what is in your master file. Many state laws and regulations make state-specific provisions regarding records. Your state board is the final word on all records-related issues and they will be happy to provide you with written direction on what your obligations are.
Next, the length of time you need to maintain inactive patient files relates both to the likelihood that any such patient may need or request those records, and your obligations under the law. There are many instances where, decades later, a patient or insurance company, relative or attorney will be looking for old information. You will need to determine the practicality of maintaining old files for such great lengths of time. There is no danger in not having those records after such a long period, even though in very rare instances, those former patients or those acting on their behalf would be pleased to obtain that information. Most states make specific provisions on how long such records must be kept. Other states address this question under the general statute of limitations. Statutes of limitations are legislative provisions that limit the time period in which legal action for damages and other complaints may be filed. A good general rule is after 7 years, since nearly all jurisdictions prohibit legal action after such a period has elapsed. This limitation is an important protection for you and your practice.
There are two exceptions to the general rule on statutes of limitations. Those concern “minors” and persons determined under the law to be “incompetent’ and unable to act on their own behalf. In most states, the law on the statute of limitations starts the limitation clock after a minor becomes an adult. On minor patients’ records, you will want to check to see if your jurisdiction has any specific provision for minors, and what the details of that provision might be. Regarding those who might be determined to be incompetent, check in each instance where this might apply to a patient under your care. Once again, you will always want to inquire of your state board, documenting their response for the record, before you dispose of any records. Always keep a copy of your inquiry and their response in your files to use in addressing any questions about your actions to dispose of old files.
No one article can adequately address all the ins and outs of such a complex subject as record keeping, or can advice given here be more than general in nature. You must understand that you are responsible, and will be held accountable for your care decisions, based on the records you keep. In the end, you have to do the work. No system of short cuts and abbreviations can do that for you. It will, please believe me, be worth every minute you invest.
American Bar Association, Section of Science and Technology, Information Security Committee: Jurisdictions with legislation regarding electronic signatures, July 31, 2006.
State of New York, Office of the Professions, Practice Alerts, 3. Record Keeping and Documentation, http://www.op.nysed.gov/chiroalertrecords.htm.
“Health & Medicine.- At risk of exposure: In the push for electronic medical records, concern is growing about how well privacy can be safeguarded.“, Los Angeles Times, 2006–06-26.
Burt, Catharine W., Ed.D.; Hing, Esther,, M.P.H.; and Woodwell, David,, B.A., “Electronic Medical Record Use by Office-Based Physicians: United States, 2005,” Division of Health Care Statistics, National Center for Health Statistics, US Department of Health and Human Services.
“Top 5 Mistakes Physicians Make,” MBA Health Group, April 1, 2009, http://www.mbahealthgroup.com/starting-a-medical-practice-top-5-mistakes-physicians-make/