Have patients review and update their health history form at every visit as well as sign and date it. "However, in order to dissuade a plaintiff's attorney from filing suit, the best documentation will state specifically what testing was recommended and why.". Copyright 2023Frontline Medical Communications Inc., Newark, NJ, USA. To make sure doctors give good care and nursing homes are clean and safe; To protect the public's health, such as by reporting when the flu is in your area; To make required reports to the police, such as reporting gunshot wounds; Your health information cannot be used or shared without your written permission unless this law allows it. The LAD remained totally occluded, the circumflex was a small vessel and it was not possible to do an angioplasty on that vessel. CDA Foundation. thank u, RN, It is really a nice and helpful piece of info. Parker MH, Tobin B. If there is a commercially available pamphlet that does a good job of explaining the reason for the recommendation, physicians should give it to the patient and note that this step was done. Essentially the case became a debate regarding a conversation with the cardiologist and the patient about whether cardiac catheterization was offered and refused. When a patient or the patient's legal representative refuses medically indicated treatment, documentation should reflect that the physician discussed the nature of the patient's condition, the proposed treatment, the expected benefits and outcome of the treatment and the risks of nontreatment. Laura Hale Brockway is the Vice President of Marketing at TMLT. The explanation you provide cannot . "He blamed the primary care physician for not following up further at subsequent visits and for not convincing him that the test was really necessary," says Sprader. American Health Information management Association. He said that worked. 1201 K Street, 14th Floor Elisa Howard
And, a bonus sheet with typical time for those code sets. We hope you found our articles Unfortunately, the doctor didn't chart the phone calls or the patient's refusal, so the jury had nothing but his word to rely upon. This applies to nursing documentation across every type of practice setting-from clinics, to hospitals, to nursing homes, to hospices. Keep the dialogue going (and this form may help)Timothy E. Huber, MDOroville, Calif. We all have (or will) come across patients who refuse a clearly indicated intervention. Don't chart excuses, such as "Medication . Do document the details of the AMA patient encounter in the patient's chart (see samples below). This contact might include phone calls, letters, certified letters, or Googling for another address or phone number, especially if the condition requiring follow-up is severe. HIPAA generally allows for disclosure of medical records for "treatment, payment, or healthcare operations" absent a written request. In some states the principle of "comparative fault" or "contributory negligence" will place some of the blame on the patient for failure to get recommended treatment. . The physician admitted at deposition that he made a mistake in not documenting the patient's refusal to have a catheterization. Document your findings in the patients chart, including the presence of no symptoms. (3) A patient's competence or incompetence is a legal designation determined by a judge. suppuration and tooth mobility). If you must co-sign charts for someone else, always read what has been charted before doing so. And the copy fee is often a low per pg amount, usually with a maximum allowed cost. like, you can't just go and buy them? While the dental record could be viewed as a form of insurance for your . Revisit the immunization dis-cussion at each subsequent appointment. The practice leader should review the number of incomplete charts by clinician each week and monitor the age of those claims. Physicians are then prohibited from proceeding with the intervention. The documentation of a patient's informed refusal should include the following: Many physicians may feel it is not necessary to document the more common instances of informed refusal, such as when a patient refuses to take medication or defers a screening test. Thanks for your comments! His ejection fraction was less than 20%, and he had unstable angina. The patient sued after being diagnosed with colon cancer. The information provided is for educational purposes only. All rights reserved. ACOG, Committee on Professional Liability. . 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