Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your Medical License

Sloth n. 1. Aversion to work or exertion; laziness; indolence; sluggishness.

This is the second of seven articles in the series "Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your Medical License." How, you may wonder, can the "sin" of sloth be extrapolated to the practice of medicine? Especially, you highlight, since the mere accomplishment of completing medical school, internship and residency itself is seeming prima facie refutation of the definition of sloth.

Sloth can be manifested in several ways. Sloth most often displays itself as failing to maintain adequate and accurate medical records. Sloth can also be failing to remain up-to-date on journals and current standards of medical practice. Sloth can be over-delegating to support staff or relying exclusively on ancillary staff to review laboratory results. Sloth can be disorganization — failing to correspond diagnostic test results with a patient's file. During the past two years, I've seen two cases where the physician missed critical laboratory or radiology data on two or more occasions. Both cases resulted in patient deaths (one from cervical cancer, one from lung cancer). Both physicians had at least two sets of data, and two opportunities, to review the information that would have lead to a timely diagnosis. Essentially, sloth is failing to appreciate the details that make a medical practice function safely and professionally.

I will concentrate on record keeping because it is the most pervasive problem we investigators see. Did you know that aside from technical violations such as failing to notify the board of your change in address, or operating without a fictitious name permit, the most common violation for a citation-and-fine is failing to maintain adequate and accurate medical records? Are you surprised to know there is a section of law that sanctions record keeping?

Business and Professions Code section 2266 reads:

During the past three years, 93 citations have been issued to physicians for failing to maintain adequate and accurate medical records. (Note: a citation-and-fine is not considered discipline. It is not reported to the National Practitioner's Data Bank, although it is disclosed on the board's Web site.) Moreover, many physicians against whom an accusation is filed (this is discipline and is reported to the NPDB as well as disclosed on the Web) are charged with failing to maintain adequate records in addition to other quality-of-care violations.

Unfortunately, I have no riveting stories to report about record keeping violations. I can tell you, however, that we investigators can visualize your dilemma. It's not necessarily sloth, per se. You're in the office, patients are stacked up in the waiting room, you know you have to chart the visit but you're so busy and the HMO/PPO's aren't paying you for charting (but just wait until you need to justify your bill...) Lackadaisical charting might be an area where a corner can be cut, where time can be saved. After all, you're being compensated for the number of patients you see, so cutting a few corners and omitting a few details from the patient's record, or failing to keep a record at all can't be that ominous of a proposition. It's not that you're lazy, it's more like you're busy...

The California Medical Association published Document #1135 in January 2006 which sets forth guidelines for the contents of medical records. Why is the quality of medical records so important? The CMA's publication stresses that not only do they serve as a basis for planning and maintaining quality of patient care; they often are the best defense of a physician in a medical malpractice action. Medical records also serve as a basis for reimbursement, and incomplete records interfere with the ability of a physician's peers to perform peer review. From the Medical Board's perspective, very often a physician who is the subject of a complaint can stop a case from going to the field for further investigation because their excellent recordkeeping skills answered all of the reviewer's questions. If our initial reviewers in the Central Complaint Unit do not have information to determine the standard of care has been breached, the case must be referred to the field, assigned to an investigator, and the resolution of the complaint takes much, much longer.

For convenience, I will share several excerpts from CMA's Document #1135. A variety of organizations are cited in the document as having jointly developed the following principles for medical record content:

1. The medical record should be complete and legible (author's note about legibility: If we cannot read your records, it is a violation of Business and Professions Code section 2266. Additionally, we will ask you to transcribe the record, which is a waste of your time and will prolong the investigation.).
2. The documentation of each patient encounter should include: the date; the reason for the encounter; appropriate history and physical exam; review of lab, x-ray data, and other ancillary services, where appropriate; assessment; and plan for care (including discharge plan, if appropriate).
3. Past and present diagnoses should be accessible to the treating and/or consulting physician.
4. The reasons for and results of x-rays, lab tests, and other ancillary services should be documented or included in the medical record.
5. Relevant health risk factors should be identified.
6. The patient's progress, including response to treatment, change in the treatment, change in diagnosis, and patient non-compliance, should be documented.
7. The written plan for care should include, when appropriate: treatment and medications, specifying frequency and dosage, any referrals and consultations; patient/family education; and specific instructions for follow-up.
8. The documentation should support the intensity of the patient evaluation and/or the treatment including thought processes and the complexity of medical decision-making.
9. All entries to the medical record should be dated and authenticated.
10. The CPT/ICD-9 codes reported on the health insurance claim form or billing statement should reflect the documentation in the medical record.

Additionally, a physician should document the fact that the patient's consent and informed consent, when required, was obtained. (author's note: Also, don't forget that accuracy of medical records means documenting errors, too. Failing to record an adverse event can result in adverse consequences to you. If you or your staff make an error in charting, it's important to simply place a line through the error, date it, initial it, and make a comment indicating where the correct entry may be found.)

The importance of proper medical record keeping cannot be emphasized enough. It may seem time-consuming to add that extra documentation, but I can guarantee it will save you more time (and money) in defending yourself and justifying your insurance claims. Just remember this: if you are ever the subject of a complaint, your outstanding medical record will serve a multitude of purposes. Not only do they serve the functions enumerated in the CMA document, they have the potential to substantially expedite the resolution of an investigation and leave your peer reviewers impressed with the high quality of your medical care!

Coming up next: Envy