I am old enough to remember the days of thick paper charts stacked in the hospital medical records department. The medical records department was usually in the basement or some dark corner of the hospital, but would always have plates of cookies and pots of coffee at hand, hoping to induce doctors to wade through the stack of charts awaiting their signature. You’d call the records department (from a hospital landline because there were no cell phones back then) to alert the staff that you’d be coming in to sign, and find a stack of charts as high as your head waiting in a little cubicle. Each fat chart would have dozens of little pink or yellow arrow stickers to indicate the areas that needed your attention. In addition to having to physically be at the hospital to sign your charts, there were many inefficiencies in this system. However, in the old days of paper, at least the rules for signing charts or amending the medical record were clear and simple. Unfortunately, since advent of the electronic medical record (EHR), the rules around documentation (particularly amending the record) and signing the chart have become highly complex.

As the Chief Medical Officer of an electronic medical record (EHR) company, I get caught up in a lot of debates about electronic documentation and chart signing. For example, hospital compliance officers often try to apply the same policies they use for inpatient medical records to the Hospital-Based Outpatient Department (HOPD). The regulatory standards are different in the provider-based setting and these realities impact the policies for documentation and signage, although the compliance officers may not understand that. Then the electronic nature of medical records makes some procedures possible that are not advisable or might not even be legal. For example, a common request is a feature that would enable an advanced practitioner to “sign all unsigned charts” simultaneously (meaning, without necessarily reading them). Is that OK? What about unlocking a chart weeks later to make a change in a diagnosis code? What about making a change in the record that impacts the billed level of service after the claim has dropped?

There are a lot of “standards” and regulations which apply to EHRs, but many require interpretation. Where regulatory flexibility exits, facilities and practitioners may be allowed create their own policies (but may not actually have written them down anywhere). Some types of programming are clearly not allowed, while others might be allowable but might expose the practitioner to a higher risk of recoupment in an audit or might “look bad” if the chart ended up in court. In those cases, who should make the final decision about whether to do it? Should an EHR enable questionable features but include an electronic warning about their risk? There are a staggering number of questions like this which require a modern Solomon to think through.

Kathleen Schaum and Donna Cartwright tackled a list of EHR documentation and signage questions in their article “Do You Have a Compliant Electronic Health Record Documentation and Signature Process?” which was just posted in Today’s Wound Clinic. The article is a must read for every advanced practitioner, nurse, manager and hospital administrator.

If you have questions of your own about this topic, send me a message with an example of the scenario in question. I will collate them and pass them on to Kathy and Donna, in hopes that they will do a follow-up article. We’ve only scratched the surface of this issue.