Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your
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:
- 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.).
- 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).
- Past and present diagnoses should be accessible to the treating and/or consulting
- The reasons for and results of x-rays, lab tests, and other ancillary services should
be documented or included in the medical record.
- Relevant health risk factors should be identified.
- The patient's progress, including response to treatment, change in the treatment,
change in diagnosis, and patient non-compliance, should be documented.
- 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.
- The documentation should support the intensity of the patient evaluation and/or
the treatment including thought processes and the complexity of medical decision-making.
- All entries to the medical record should be dated and authenticated.
- 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
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