Straight Talk Tuesday

I’d like to have some straight talk about the Hospital Based Outpatient Clinic, electronic medical records, and the misconception that two people can chart in an EHR at the same time in that setting. The hospital based outpatient wound and hyperbaric department provides patient care “incident to” a physician service. That means that the physician is responsible medically and legally for the care provided by all the other clinicians, even though those caregivers are not employed by the physician. When the physician signs the chart, he or she is also acknowledging the documentation of all the individuals in the chart and is attesting: 1) that they have read the chart and are familiar with its contents and 2) they know what treatments were performed and are responsible for the care provided by all the staff members in the wound and hyperbaric center.

Let’s talk about how 2 clinicians (usually the doctor and the nurse) could chart in a patient’s record at the “same time.” One method is to have an entirely separate clinical chart for the nurse which the physician is not required to authenticate, review or otherwise acknowledge in order to allow nursing documentation to proceed independently. It is this “feature”, which some hospitals allow under the excuse of improved “work flow”, that led to the death of an Ebola patient. The physician was not required to review the nursing documentation which contained information pertaining to travel and other infectious disease exposure. Allowing a separate documentation area to exist for the nurses is inconsistent with collaborative care goals and is dangerous.

Another way EHRs may facilitate the charting of two individuals is via the “last one in” method. In these systems, the clinician is not actually documenting in the chart when they are entering data. Data is not actually entered until the clinician “submits” the data (similar to placing an on-line order) which the EHR may disguise by making it appear to be a “signature” sign off. This means that both clinicians who BELIEVE they are charting are actually creating a temporary document. The clinician who submits their document last can over-write the entry of the prior clinician and the prior clinician has no way of knowing this happened. The problems for the physician in the hospital outpatient department are significant. For example, a nurse might document that a wound has no necrotic material in a patient who just underwent a significant debridement for necrotic tissue. If the chart undergoes a recovery audit, the physician is at risk of significant recoupment due to the discrepancy in charting. Numerous cases like this have been documented in wound centers in which money was paid back due to charting discrepancies between the nurse and the doctor. This is not only a financial liability but a medicolegal liability when the staff members, all of whom are providing care incident to the physician, have the ability to create or change documentation without the review of the physician under whose supervision the services occurred.

So, for all the doctors who think that allowing a nurse to document or change documentation in a chart without the doctor’s specific review being required, think about how you will feel writing that big check to the Medicare RAC auditor, all in the interest of better “work flow.”