Legal Aspects of Documentation & Compliance - Week 7 Flashcards
What do you need to always remember about the patient’s medical record?
- Legal document that is admissible as evidence in a court of law
- Patient record is presumed true
- Documentation should reflect scope of practice that is within the legal description provided by the state
- Any question that surfaces in a legal proceeding can be answered based on the content of your documentation
- Single most important evidence of the PT’s judgment, actions, skills, and decision-making
- Overseeing health care professional for the patient is responsible to keep health information accurate, timely, relevant, secure, and confidential
Documentation Supports or Refutes Medical Malpractice
- Prove that the health care provider was negligent
- Nonverbally explain how the provider met the prevailing professional standard of care (duty)
- “If it’s not documented, it didn’t happen”
What should your documentation contain?
- Detailed enough so another practitioner can assume the care of the patient with no questions asked
- Clearly identify important characteristics of the patient, support the diagnosis, justify treatment, and establish outcomes reached
- All significant information about the patient should be included; all communication among caregivers and other health care providers
- Continuity of clinical decisions; implementation of plans; evidence of patient’s care; goals achieved
- Reasonable and necessary skilled care
- Treatment notes reflect what care the patient received and patient response
- Progress notes refer back to initial examination and goals to demonstrate progress
- Any refusal, inability to take part, missed visits, and why
What are some common legal documentation problems and pitfalls?
- Parrot Documentation (document the same thing each day
- Technical Omissions (not including specific content - ex no date or adding codes)
- Illegible Entries (if still hand writing)
- Undefined Abbreviations
- Lack of Substance (not alot of detail)
- Lack of information to support if standard of care has been met
Electronic Health Records should always ….
Electronic Health Records should always be pasword protected, with auto logoff screens and comply with federal and state regulations for security and privacy measures.
- Comply with federal and state regulations for security and privacy measures
- Password protect with auto-logoff
- Privacy screens
- Avoid use in public places
- EHR policies and procedures
What are the components of informed consent and how do you document it?
- Document: PT gave information; Patient understood & consented to the proposed treatment
- A description of the treatment to be provided
• A clear explanation of the risks that may be
associated with the therapy
- Expected benefits from the therapy
- Anticipated timeframes
- Anticipated costs
- Reasonable alternatives to the recommended therapy
- For PTs varies by state
Medical Record Content
- Signed consent for treatment
- Referral if indicated
- Privacy notice receipt acknowledgement • Insurance verification
- Copies of any pertinent reports
- Evaluations/reevaluations
- Plan of care
- Daily visit/encounter notes
- Progress notes
- Equipment information; Flow sheet
- Discontinuation summary/conclusion of episode of care
- Letters/communications
- No show/cancellation
- Service, billing, activity logs • Letters of medical necessity
Confidentiality
All information regarding the patient’s/client’s care must be kept confidential and in a secure area with access limited to appropriate staff
incident report
What are some of the do’s and don’ts about incident reporting?
not part of the patient’s medical record and can be used in litigation
- Not part of the patient’s medical record; Can be used in litigation
- Informs administration: root cause analysis can be performed; prevent reoccurrence
- Notify referring physician or other health care provider immediately, existing signs/symptoms worsen, or new signs/ symptoms develop
- Ensure patient/client receives appropriate care after incident
- Record only factual information; give report to supervisor
• Do not discuss the relative guilt or innocence of anyone
involved or problems with equipment used
- Do not make inferences related to cause in the report
- Do not discuss with patient after event
Maintaining Patient Records
- State laws govern how long medical records are to be retained
- Legal requirements for retention of business records which may include medical records
- HIPAA requires a covered entity to retain required documents for 6 years from the date of its creation or the date when it last was in effect
- Statute of limitations: time limit after an incident by which an individual must file a lawsuit; retention periods must exceed statutes of limitations
- Regulations in Medicare Conditions of Participation
Statute of limitations
time limit after an incident by which an individual must file a lawsuit; retention periods must exceed statutes of limitations
What is the purpose of the State Boards of Physical Therapy Practice?
- Disseminates the rules and regulations governing the profession of physical therapy
- Oversee the state licensure of physical therapists and physical therapy assistants
- Review complaints brought against physical therapists, physical therapy assistants, and students for violations of the practice act
General Supervision
The PT is not required to be on site for direction and supervision, but must be available at least by telecommunications
Direct Supervision
The PT is physically present and immediately available for direction and supervision. The PT will have direct contact with the patient/client during each visit- defined as all encounters with that patient or client within a 24-hour period
Direct Personal Supervision
The PT, or where allowable by law, the PTA is physically present and immediately available to direct and supervise tasks that are related to patient/client management. The direction and supervision is continuous throughout the time these tasks are performed.
