The processes of medical recordkeeping continue to change, as regulators more frequently set new requirements, and many healthcare organizations struggle to keep up with the changes.
But the big problem is that too many hospitals and practices still haven’t managed the basics of collecting and reporting data for regulators and attorneys, Isabelle Bebit-Kilinyak, a corporate attorney in the McDonald Hopkins law firm in Cleveland, noted during an educational session at the Medical Group Management Association’s annual conference.
“We still see too many errors in data,” she asserted. “Signatures cannot be read, required information is omitted, and relevant information also is omitted. Who is keeping track of physical signature logs?”
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Too often, providers are not ensuring that patients and families understand basic necessities, such as when a patient needs to take medication. These mistakes could end up resulting a lawsuit.
Many providers do not know that if the medical record is a combination of paper and the electronic health record, and that information is not scanned into the EHR, then all of the documentation has be given on paper. Further, providers are releasing information prematurely that should have first been assessed first under legal review.
Healthcare organizations create massive amounts of medical images but the doctors may or may not get all the needed images for a specific reading, so another process needs to be created to make it easy for clinicians to access the images they want.
One of the most dangerous medical record practices is the texting of patient orders in hospital settings, Bebit-Kilinyak cautions. That’s because texts can go anywhere and do go everywhere, causing a breach of privacy.
“Here’s another issue to ponder,” Bebit-Kilinyak told the MGMA audience. “If a doctor sells the practice or dies, think of the software licenses of that physician and ask yourself who owns the software licenses now?”
Further, if a provider group is thinking about erasing unneeded hard drives, the provider faces risks if doing the job itself, she warned. “When shredding or otherwise destroying hard drives, don’t attempt to do it yourself. Use your vendor or another technology or consulting source.”