Moderator: Bill Finerfrock
September 11, 2007
1:00 p.m. CT

Operator: Good day and welcome to today's RHC technical assistance conference call. As a reminder, this call is being recorded.

I would now like to turn the call over to Mr. Bill Finerfrock. Please go ahead, sir.

Bill Finerfrock: Thank you, operator. Before we begin, I would be remiss if I didn't take this opportunity to ask for a moment of silence on this the sixth anniversary of 9/11 to remember those whose lives were taken on that tragic day and to also give thanks for those who are currently serving our country in a variety of capacities overseas so if we'd just take a moment here please.

Thank you. I'd like to welcome callers and participants to today's presentation on documentation. If it wasn't documented it wasn't done. Documentation omissions in rural health clinics are not just a liability issue; they're also a program compliance issue. Complete documentation can save your survey. I am Bill Finerfrock and I'm the executive director of the National Association of Rural Health Clinics.

Our presenter today is BethAnn Perkins, a principal with Health Consulting Strategies, Grand Ledge, Michigan, and one of the authors of the book "Starting a Rural Health Clinic; a How-To Manual". BethAnn will address how the RHC documentation regulations apply to your clinic and will help your clinical staff understand their role in documentation compliance and will answer your questions at the conclusion of her presentation.

Today's program is scheduled for one hour. The first 45 minutes will consist of the speaker's presentation, slides have been made available, with the remaining 15 minutes dedicated to questions and answers and discussion. The call series is sponsored by the Health Resources and Services Administration's federal office of rural health policy in conjunction with the National Association of Rural Health Clinics. The purpose of our call series is to provide rural health clinics' staff with valuable information and RHC-specific information.

Today's call is the twentieth in this series which began in late 2004 and will continue at least for the next five years. There is no charge to participate. We encourage you to refer others who might benefit from this call series to sign up and receive announcements. To do that and to get the presentation even for today's call you can go to www.ruralhealth - that's one word - R-U-R-A-L-H-E-A-L-T-H - .hrsa.gov/rhc. During the question-and-discussion segment we will request that callers please provide their name and location before asking their question. If you have any questions in the future, you can e-mail me at info - I-N-F-O- @nahrc.org and put RHC teleconference question in the subject line.

I want to remind everybody to follow along on your PowerPoint presentations and BethAnn if as you change pages in your presentation you would just give a verbal cue to folks we'd appreciate it. I want to thank everyone for participating and we look forward to hearing your presentation.

BethAnn, it's all yours.

BethAnn Perkins: Thank you, Bill. And I would like to thank the National Association of Rural Health Clinics for this opportunity.

RHC clinical documentation is near and dear to my heart as a registered nurse by background, I probably am one of the few nurses in the country that have reviewed thousands and thousands of dates of service and medical records in the last 15 years of participating with the rural health clinics program so it is a privilege to be with all of you today.

Today, I want to talk about the documentation requirements for the rural health clinic program; is it different than documentation requirements in an ambulatory care setting, in a hospital, or in a nursing home? I also want to talk about clinical documentation standards and expectations as well.

To start out with, I just want to say that charting or documentation is the process of preparing a complete record of a patient's care. Remember that the patient's chart reaches a wide audience so it must be easily retrievable and readable. The medical record is often reviewed by other members of your clinic staff, by surveyors, reviewers from accrediting and licensing organizations, Medicare and insurance company reviewers, lawyers, and judges. So your documentation must be clear, it must be concise, and organized. I will also point out how this is a requirement for the RHC program as well. It is the record of what you do for your patient and it is written evidence that the care that the patient receives is necessary. Proper documentation communicates crucial, clinical information to the healthcare team so that they make fewer errors.

Let's go on to the first slide.

We're going to cover RHC visit definition and face-to-face encounters just as a refresher because it will have some relevance later on in the presentation as we talk about the local coverage determination, the LCD. An RHC visit defined by Medicare as a face-to-face encounter between the patient and a physician, a physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner, visiting nurse, clinic psychologist or a clinical social worker during which an RHC/FQHC service is rendered.Next slide.

RHC services are limited to physician/extender services, services incident to those physician/extender services, and under limited circumstances visiting nurse services. As many of you are familiar, in order to qualify for visiting nurse services you have to be located in a designated visiting nurse shortage area which those are few and far between. Physician/extender services are further defined as those professional services performed by a physician for a patient including diagnoses, therapy, surgery and consultation thereby codifying the distinction between a visit and a nonvisit incidental service. In terms of the face-to-face encounter, that requires, as Bill often refers to, a “laying on of hands.”

It requires the direct interaction between the practitioner and the patient (we’re on to slide number four) for the purpose of providing evaluation and management services at a skilled level that required the assessment, clinic reasoning, and judgment of a qualified RHC practitioner. The condition of the patient must warrant the specialized skills of the qualified RHC practitioner.

I want to be clear that the focus of this presentation is not to address coding compliance but rather to address the standards of documentation and also the requirements of the Rural Health Clinic program.

(Next Slide) An encounter between a clinic patient and a physician, physician assistant, nurse practitioner, nurse midwife, or (for visiting nurse services) a visiting nurse. Clinical psychologist and social worker encounters are visits in an FQHC environment and an RHC setting. Podiatrists, optometrists, dentists, and chiropractors are physicians for certain procedures; however they are not licensed to provide general medical care. To be paid on the Medicaid side, these services must be part of your core Medicaid services for your state.

Next Slide. The face-to-face encounter with a podiatrist, optometrist, dentist, or chiropractor may constitute a valid face-to-face visit if the provider is acting within the limits of his or her specialty and no other coverage and medical necessity restrictions apply. However, they are not able to supervise physician extenders in the provision of RHC services nor do they qualify as physicians for the purpose of determining physician coverage, i.e., MD or DO must be present to consider the hours “physician covered.”

Why chart? The medical record is a legal document and it is used to protect not only your patient but your practice. Proper documentation serves to provide professional accountability as well as to help meet credentialing and regulatory demands. We'll discuss the regulatory demands a little further in my presentation and how this is relevant to the RHC program. There is actually an entire condition that has been set aside for RHC records. This points out the relevance of other licensing and accrediting agencies.

The medical record provides evidence necessary for private parties, insurance companies, and governmental agencies to provide payment for services rendered. The documentation could take on many forms, whether they are in paper form or in electronic form. The focus of my presentation is not to discuss the merits of various charting systems, paper, or electronic but to discuss the fundamentals of clinical record keeping.

Next slide: RHC program documentation. In the regulation 491.10(a)(3} says, “For each patient receiving healthcare services the clinic maintains a record that includes as applicable identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and healthcare needs of the patient and a brief summary of the episode disposition and instructions to the patient.

I'm sure several of you who have participated in the RHC initial or recertification survey had been caught during the medical record review, in particular, as it relates to informed consent with procedures. We're going to talk a little bit about that. This is a requirement of the RHC program which you will find in the records requirement. Some clinics have misunderstood this requirement to mean a general consent to treat. Although many surveyors look for a general consent to treat, this really addresses informed consent as it relates to procedures.

I want to talk about charting defensively, meaning to be protective. With proper documentation you protect your patient and yourself. Chart only what you see, hear, feel, measure, count, and experience not what you suppose, infer, or assume. Chart as if the words you write reflect the actual and complete record of the care rendered because they must.

Remember this is a legal document. Ask yourself with regards to your charting is my charting chronological, is it comprehensive, is it complete, is it concise, is it descriptive, it is factual, legally aware, is it legible, objective, relevant, specific, standard and consistent with abbreviation and symbol usage. For example, oftentimes when I review medical records and I review the documentation of the medical support staff I get for the chief complaint, “Patient here for med refill. “

Is this descriptive? Not really. A more appropriate way to document the chief complaint would be, “Patient here for evaluation of medication management.” The mere fact that the patient requires a medication refill tells you that the provider would like to evaluate the effectiveness of the medication.

I know that many of you are wearing ten hats, I know that your practices are very busy, but you need to be cognizant that what you write in the record you are accountable for. I believe oftentimes medical support staff somehow feel that the only person who might be accountable for documentation in the record is the provider and that is not true. I would ask you to pause for a minute and start taking a look at actually how your medical support staff is documenting as they're rooming a patient.

I want to talk a little bit about informed consent. According to (Stedman's) medical dictionary, 26th edition, invasive is defined as a procedure requiring insertion of an instrument or device into the body through the skin or body orifice for diagnosis or treatment. Certain injections such as local cortisone injections and immunizations require consent. Minor office procedures including all types of skin biopsies (shaved, punched, excisional), ingrown toenail removals, incision and drainage (I&D) of abscesses, and excision of skin legions (e.g.,sebaceous cysts). If there's any question about whether a consent form is needed, I would suggest applying the definition of invasive. If there is still doubt obtain the consent anyway.

I want to talk about who obtains the consent. It is the responsibility of the provider (physician, physician assistant, nurse practitioner, or certified nurse midwife) to inform the patient of the procedure; and to inform the patient of the risks associated with the procedure and any other outcomes. The consent is written assurance that the patient understands completely.

The provider may ask you to witness the patient's signature and when you do that you are indeed witnessing and you are verifying that the patient is the right patient, it is the right procedure, and you have verified that the patient has been informed by the provider regarding the procedure. You are also verifying that the patient completely understands the procedure that they are about to have performed and that they understand the risks and any consequences . If for any reason the patient cannot assure you of that, then it is your responsibility to notify the provider and have them review that the procedure again with the patient.

So I want you to know that just because you are the witness to a consent doesn't mean that you don’t have any responsibility.

Next Slide: In regulation §491.10(a)(3)(ii) it says, “Reports of physical examination, diagnostic and laboratory test results and consultative findings are in the record.” In the next regulation §491.10(a)(iii), “All physicians orders, reports of treatment and medications and other pertinent information necessary to monitor the patient's progress.” And in the next regulation, §491.10(a)(iii), “Signatures of the physician and other healthcare providers.”

Let's talk about signatures. This seems to be kind of a hot item every time I review records. Generally speaking, what I find as it relates to the medical support staff and we will talk about provide staff later in the presentation. But as it relates to the medical support staff, generally speaking I either see no signature or I see some initials. You need to know that the standard of care and expectation is that it will either be your full name and credentials or first initial, last name, and credentials.

Additionally, the standard of care for nursing is heading in the direction of printing your documentation instead of writing it in cursive and then authenticating it with your signature. Right now, - you'll see cursive writing as it relates to documentation in the paper record. The standard of care for nursing is really headed in the direction of printing your chief complaint and any other findings from the patient, then authenticating it with your signature.

As it relates to computerized systems, many of you who are working with those right now, often your password is your electronic signature. I probably don't have to say this once because you've probably heard it a million times: you need to protect it, do not share it, it is what holds you accountable for the care that you provide.

I want to talk a little bit now about flow charts. Flow charts are very popular, they're very useful, they can really cut down on documentation time. I just want to remind you that unless the information on the flowchart appears elsewhere in the medical record your signature is required on the flowchart. If you have a vital sign flowchart for instance, or a blood sugar or coumadin flow chart and this is the only place where you record these measurements or values then your signature is required on the flowchart. If you record these measurements or values in the progress note and you sign your progress note then your signature's not required and initials are sufficient.

With regards to growth charts, I see a lot of incomplete growth charts What I mean by incomplete, is oftentimes either the measurements will be recorded or the measurements will be plotted but both aren't available on the growth chart and you need to be aware that both plotted measurements and recorded measurements must appear on the growth chart. The growth chart must also be complete; it must have the patient's name and the patient's date of birth.

Medication flowcharts, now we love those. Medication flow sheets are wonderful and they're definitely a quick - over view of how the patient has been managed with their medications. They can also be your downfall in a survey because oftentimes they are not kept up. I know with electronic medical records this becomes moot because a lot of times when a medication is ordered in the progress note it automatically crosswalks over to the medication flow sheet. If that is occurring in your organization, then, awesome and you can turn a deaf ear to what I'm about to say. Many of you, you are still on a paper system and in a paper environment; so your medication flow sheets really get the best of you in a survey. You need to know that medications must be updated with each visit and documented as such. Any changes in medications during the visit must be reflected on the flow sheet. This is important as other providers might - may make clinical decisions based on the integrity of the medication flow sheet. The medication record should list all maintenance and PRN medications non-prescriptive medications, dietary supplements, drug allergies, and reactions to any medications or supplements.

I want to talk now about checklists, flow sheets, or progress note templates. Once again they are wonderful tools and they really can cut down on the documentation time. However, my experience has been that 90 percent of the records t I review utilize the progress note template inappropriately. They are not complete and they do not reflect the care that has been given during the visit. Let me elaborate, basically do not check something unless you ask about that system or perform that function, do not commit fraud. Often I will see templates that have a review of systems with boxes next to each system. They will also have a section where you can document and chart abnormal findings, and I will see a line drawn through all the boxes in all the systems. I then see nothing documented for abnormal, yet when I get to the assessment I find that there is an acute diagnosis. When I get to the plan, I find that diagnostics have been ordered, x-ray, labs, and I will often find that there's been a medication ordered as well.

Now, I got to tell you that there is nothing normal about that visit. As medical support staff if you find that in the record I would suggest taking the record back to the provider and say, “You have outlined a plan here that includes labs, diagnostics, and medications I don't see your objective findings. Would you take a minute to include those?” Whenever, you know, you have a plan that deviates outside of a preventative visit and 90 percent of what you do deviates outside of a preventative visit, there needs to be objective findings.

Let's talk about injections. What I find with injections is that it's just documented. The provider has ordered an antibiotic injection (rRocephin) to be given and the medical support staff documents that the injection (Rocephin) was indeed given. Or, the patient is a pediatric patient and has come in for their immunizations. The immunization flow sheet will have a place for you to document the site of administration. I often find that that the site of administration is not documented on the immunization flow sheet.

So remember when you are giving an injection as medical support you are to document the name of the medication, the dose, the route of administration, Sub Q), IM, IV, site of administration, the gauge of the needle, and the patient's tolerance to the medication, followed by your signature; if your signature does not appear anywhere else in the medical record.

Next slide: RHC interpretive guidelines. These would be instructions to the surveyor. The Guidelines state, “Examine a randomly selected sample of health records to determine if appropriate information (as related to the regulations that we just reviewed) ncluded. This listing is the minimum requirement for record maintenance. Many of you I know have had poor outcomes to your survey as a result of the medical record review. Often you have experienced where the surveyor has done a couple of things. One, they've either gone to your medical records and said, “jGive me five records, give me 10 records.” They've gone to your scheduler and they've - picked out patients on your schedule and said I want to see those records, those records, and those records. Or if you are very fortunate they've looked at you and said I just want to see five or 10 medical records. For those of you who had that happen to you, you should have had those five or 10 picked out ahead of time so you were giving them your very best.

I also want to take this time to just talk about and cover prescription writing because again that's an area where I see a lot of deficiencies in the medical record. Understand that there are elements to a prescription that need to be included with every prescription whether it's for a non-controlled or controlled substance. Those elements include: the date the prescription is written, the prescriber’s name and credentials, patient identification, which, at the very least, includes their name, date of birth, and in some states may require age and address. The name and strength of the medication, the unit or doses to be dispensed, i.e., milliliters, or grams, instructions on how to take the medication, and indications for use (to be used for relief of arthritis, or arthritic pain). What this does is this provides an additional check for the prescriber, pharmacist, and the patient. Refill information should also be included.

There are several common errors in prescription writing that studies have shown. I'm going to cover just a few of them. One is the legibility of any part of the prescription, omissions where a provider has left off the drug name, strength, quantity to dispense, dose or direction error, or they've exceeded the recommended dose or they've not indicated for a PRN medication, unclear quantity prescribed. So the quantity does not match the directions, incomplete directions, not identifying the route, quantity be taken at each dose, frequency of dosing, and incomplete, that could have implications as it relates to the medication, antibiotics for example, is it an ointment or ingestible. Then also using leading and trailing zeros; not putting a leading zero before a decimal expression of less than one and including a trailing zero after a decimal. For instance, ordering a prescription with (Lanoxin), .125 milligrams instead of writing (Lanoxin) 0.125 milligrams or Coumadin 7/30, 13.0 units instead, it should be written Coumadin 70/30 13 units.

Another big issue that I see in the records has to do with verbal orders and telephone orders for a refill. Oftentimes I will see in the medical record that the patient has called in requesting a refill of their medications and the telephone order will generally have the date, the patient's name, and even the time of the call, and then in the medical support or the reception staff will write request refill of medication. What I see from the provider side is, “OK”. Or, I will see a request for a ongoing medication, i.e. Lanoxin) and it'll just say (Lanoxin). On the provider side it'll say, “OK” with their initials or a signature. You need to know that the mere fact that a prescription has expired means it requires a new prescription, and the mere fact that now the patient requires a new prescription means that the prescription must be complete, as I've just discussed, and it must be signed by the provider.

And I know for many of you, you're looking at each other and you're thinking we do tons and tons of these, a day. It is what it is and it is the requirement for a prescription. As I've said before, medical standards that you're accustomed to in a inpatient setting don't change just because you walk into ambulatory care or you walk into the rural health clinic program. They are still governed by standards of care, standards of practice, and state law.

On to the next slide, slide 10. We're going to talk a little bit about record management. The RHC medical records management requirement §491.10(a) Record system states, “The clinic or center. (when the regulations refer to clinic or center, clinic refers to the rural health clinic program and center refers to the federally qualified health center program) maintains a clinical record system in accordance with the written policies and procedures.,Number two, a designated member of the professional staff is responsible for maintaining the records and for ensuring that they are completely and accurately documented, readily accessible, and systematically organized. Generally speaking, that designated member is either the medical director, or if your practice is owned by a PA, a nurse practitioner, or certified nurse midwife the physician extender/owner would be designated as the professional staff person responsible. But in general it is a licensed staff member who is designated as assuming responsibility for maintaining the records. I really wouldn't take that lightly because again this gets cited in a survey.

Next slide:
Protection of record information §491.10(b). The clinic or center maintains the confidentiality of record information and provides safeguard against loss, destruction, or unauthorized use, written policies and procedures govern the use and removal of records from the clinic or center and the condition for release of information.

HIPAA has really tightened this up for rural health clinics but if any of you've heard me present in the past with regards to QAPI, the quality assessment performance improvement, you know that I've said all along that RHCs were ahead of the power curve as it relates to HIPAA because this has always been a requirement for us. It's just that HIPAA has put some meat to the regulations and has provided a more comprehensive framework.

But I also want to point out that for those of you who have more than one clinic and you have patients that are seen in some of your other clinical sites that you have to have a policy that defines how you will transport records. If you transport records from one clinical site to the other, you must have a policy that addresses how you will secure those records, how you will safeguard them, how you will protect and maintain confidentiality.

Next slide. (In) three, the patient’s written consent is required for release of information not authorized to be released without such consent. Again, this falls under HIPAA. Many of you have been HIPAA'd to death so I don't need to go into this any more. In §491.10(c) Retention of records. The records are retained for at least six years from the date of last entry and longer if required by state statute.

For many of you, your liability carrier will recommend that you retain your records indefinitely and so you will follow the requirements of your liability carrier. Others, you will have state statutes that requires you to retain records longer than that. And, of course, there are state statutes governing the retention of pediatric records that would go beyond six years of the last date seen.

Next slide. Now we're going to get into, the LMRP or - now know as the LCD or Local Coverage Determination.– The LCD is from Riverbend. Riverbend really took the lead with (fiscal) intermediaries in really defining some of the medical record requirements as it relates to payment policy and Trailblazers, National Government Services, many of the others have followed suit. But really it all started with Riverbend, so this is the document that I am going to be using. What it says here is, “Each page of the medical record must be assignable to a specific patient by some form of identification, either a complete patient name or a unique medical record number.

Each face-to-face encounter documented in the medical record must include the date in which the encounter occurred or in the case of multiple visits on a single day the date and time of the visits, and for this reason that's why I included the definition of a face-to-face. I also want you to know that the standard of care for nurses and physician assistants takes us one step further to say that the date of birth must also be present on each encounter documented.

Next slide. Going on, the LCD signature requirements and I know that there's been lots of discussion on this. The provider signature may be appended to the medical record in any of several formats but in all cases must be sufficiently unique to allow both the provider and Riverbend to determine unequivocally at a later date that the provider personally affixed the signature. The signature should be - should be legible but must at a minimum be ideaographic, (a consistently reproducible and unique autograph). A full name, John Smith or last name and credentials Smith, MD, are necessary for the signature to stand alone. And what I often tell providers because providers will say, that's my signature and it looks like an x with a circle around it, is that your signature on your legal documents. If you are signing a mortgage, is that the signature that you would use to sign your mortgage, and if it's not, then it is not acceptable for documentation standards.

Next slide, going on with signature requirements, if the signature services to authenticate a typed, stamped, dictated computer-generated signature or a third-party signature, it must still be sufficiently unique to unequivocally identify the author. Printed initials are inadequate for that purpose. A last name or script initial is usually the minimum appropriate validation. So that really pertains to those of you who have transcription and the transcription comes back with the provider's initials. The typed initials alone are not enough to validate the authenticity of the note. It does at a minimum require their script initial. Excuse me. If credentials are not appended to the signature, the credential's associated with the signature, must be apparent elsewhere in the documentation.

Next slide. Going on, the LCD talks about handwritten entries. Since the entry itself is ideographic, the signature need only include enough legible information to identify the provider. A last name is generally sufficient. If the facility wishes to keep a signature registry of its providers, a page with signatures and typed or printed entries identifying the owners of the autograph, it can provide a copy of the appropriate entry with any requested records in order to allow the decoding of illegible ideographs. Because the medical record is - and I'm going to get to that - back up for just a minute, there's been lots of discussion when I go into a practice and a lot of discussion in terms of having a signature log.

I personally don't like them and the reason that I don't like them is because they're never kept up and oftentimes providers and medical support staff change and the signature log doesn't change with them. Also, I've had some experiences where when the clinic has been asked to produce the signature log it's been such a long time since they've updated it they can't even remember where they put it. So I'm not a supporter of a signature log or a signature registry but, you know, this is what Riverbend has to say about it.

Bill Finerfrock: We got about five minutes.

BethAnn Perkins: Also, because the medical record is a permanent document when using a paper system, documentation should be completed in ink or by computer. Use only black or blue ink. Red or green ink does not photograph clearly and pencil is never allowed.

In the dictated entry, a dictated-type signature must be countersigned as validation by the provider who performed the face-to-face confirming that the provider has reviewed the dictation and verified that it is correct.

Next slide. I want to talk a little bit about stamped signatures. A stamped signature is acceptable as long as the facility has implemented procedures which clearly establish ownership and control over the access to the stamp. The physicians or extenders must be able to affirm that the stamp is available to them alone and that sufficient controls exist such that the stamped signature can be identified as being personally affixed by the provider and therefore equivalent to an inked autograph and that single affirmation should be kept on file at the facility. So basically, the stamp either has to be on the provider's person or locked at all times.

And then I want to talk about prescription pads with this. It seems like a good place for that. Prescription pads should never be pre-signed. A prescription pad should be kept with the provider and the additional pads locked and secured. An inventory of all provider prescription pads should be conducted on a weekly basis to ensure that none are missing and it is the responsibility of the provider to determine what medications - this is in general to writing prescriptions which should have gone a little bit before this, but I just want to make the point that it is the responsibility of the provider to determine what medications the patient is taking at every visit before writing any prescription. Just know that prescription pads must be secured. I've been in a number of facilities where I found them out on the counter.

In terms of computer-generated - next slide - paper records are an analogous to dictation. The typed signature must be countersigned by the provider who performs the face-to-face confirming that provider has reviewed the computer-generated record and verifies that it's correct - that it was correct.

And the next slide, as it relates to EMRs and EHRs, purely electronic records are those that are stored electronically and printed only when the documentation is needed by a third party such as Riverbend and affirmation from each physician/extender that entries are password protected and only the provider (that) has access must be kept on file, and then you'd just have to provide that to Riverbend with the request.

In the next slide, I just want to go over the legal expectations of medical record documentation that all findings are essential to a diagnosis or patient care, that all findings positive or negative are customarily documented in a similar situation, that records should be consistent and continuous processes that are unchanged need not be documented. I want to take a moment to talk about correcting chart entries. Medical records and hardcopy (or) computer form are legal documents providing proof of the care patients received and the response to that care. Medical records that are poorly maintained, incomplete, inaccurate, eligible, or altered create doubt regarding the care given to the patient.

When charting an entry error, never erase or try to hide it. Draw a line through the error and write, “Mistaken entry”, which is new. For those of you who've been in nursing for a long time we used to write error. Now you and draw a line through the error and write, “Mistaken entry”, followed by your signature and date. Never use whiteout on charts.

With regards to late entries, you may occasionally need to add a late entry in certain situations such as when the chart is unavailable. In that case, you would documented with the date and time that you are actually making the entry, followed up with late entry and the reason that the entry is made. Then,give the date and time that the entry should have been recorded, followed by your account or documentation, concluding with your signature.

Next slide, legal expectations, continuing the description of an examination should clearly identify what was examined, document the possible diagnosis and complications that are being considered, and all boxes, blanks, or checklists on the medical record form should be completed. I want to just review some charting don'ts: don't record staffing problems, don't record staff conflicts, don't mention incident reports, only chart the facts of the incident in the chart, and never write incident report or indicate that you've filed one, don't use words associated with errors, terms like mistake, accidentally, somehow, unintentionally, miscalculated, and confusing, don't name a second patient, and don't chart casual conversations with colleagues.

Next slide, legal expectations continued, document medical complications, mishaps or unusual occurrences in the medical record, use terms that reasonably reflect what happened and do not misinterpret the facts, avoid expressions that imply disapproval or negative value judging of the patient.

Next slide, avoid expressions that imply the patient's complaints are not being heard or taken seriously, describe your assumptions about the patient's - you know, these are dos - describe your assumptions about the patient's motives as possibilities rather than a statement of fact, and do not document your frustration with or disapproval of difficult patients.

Well, the next slide just about sums it up and that is, “if it wasn't documented… we know the answer to that, it wasn't done”. In all of the resources that I've used throughout the years this statement appears time and time again, so once again, “If it's not documented, it wasn't done.” I don't care what your intentions or how good your intentions were.

And then the next slide again, problems with documentation, EMRs address some of this and takes care of a lot of it, but the bottom line, you can have a electronic template in an EMR and if you're not using it appropriately, you will still have issues. So problems are eligible documentation and adequate documentation that does not support the visit level (billed). Missing documentation, you have diagnostic reports but you don't have an order, you have an order but you don't have diagnostic reports, phone notes that have no follow-up, you have a request for prescription refills but you don't have a complete prescription, and that the documentation does not meet the RHC program requirements.

So basically, I mean, what you have here are there are expectations in the medical record by both the RHC program and by your payers, by the (fiscal) intermediary, but they are congruent and consistent with the standards of documentation that have some, you know, been there since the - you know, for nursing since the days of Florence Nightingale didn't change. When you moved into the RHC environment or the ambulatory care environment the documentation standards did not change.

Lastly and my last slide, just don't let this be you: Ms. Daily have there been any important e-mails or voice mail during my incarceration. So make sure that your documentation is legible, concise, and complete.

And that concludes my presentation. I again would like to thank the National Association of Rural Health Clinics and the Office of Rural Health Policy for this opportunity. Bill, I'll turn it back over to you.

Bill Finerfrock: Great. Thanks, BethAnn. That was a wonderful presentation and I think folks will find it extremely helpful and educational.

At this point, we'd like to open it up for questions for BethAnn. I want to - operator will give you instructions. We would ask that at prior to asking your question you identify yourself by name, first name is all we need, and then also what state you're calling from just so we can get a sense of where our questions are coming from.

So operator, if you'd give the instructions.

Operator: Thank you, Mr. Finerfrock. The question-and-answer session will be conducted electronically. If you'd like to ask a question, please do so by pressing the star key, followed by the digit one on your touch-tone telephone. If you are using a speakerphone, please make sure your mute function is turned off to allow your signal to reach our equipment. We'll proceed in the order that you signal us. Once again, please press star one on your touch-tone telephone and we'll pause for just a moment to assemble the queue.

And we'll take our first question at this time.

Bill Finerfrock: Go ahead, caller.

(Tonya): Hi. My question is . . .

Bill Finerfrock: Your name and state.

(Tonya): Oh, I'm sorry. (Tonya) calling from ((inaudible)) Kansas ((inaudible)) Medical Clinic . . .

Bill Finerfrock: OK.

(Tonya): . . . and my question is, is a stamp acceptable on dictation in the permanent chart if it's just a block letter stamp, it's not initials, it's not handwritten signature, it's just two initials and the date? Is that acceptable?

BethAnn Perkins: No. It has to be a handwritten - their initials - handwritten initials or it has to be their signature stamp and I just want to also address that in another area. I've had folks say that for billing purposes that they have had provider's signature stamp that have been utilized on claim forms that have gone in.

Again, that is unacceptable. The signature stamp - it's very clear the signature stamp must only be in the possession of the provider and when not in the possession of the provider it must be locked. And in terms of, (or) authenticating dictation, it either has to be with their written initials or with their signature stamp or signature.

(Tonya): OK, thank you.

Bill Finerfrock: OK.

Operator: And just as a reminder, it is star one to ask a question.

Bill Finerfrock: … question?

Operator: And we'll take our next question.

Bill Finerfrock: Go ahead, caller.

(Tina Davis): Hi. My name's (Tina Davis) and I am from the (Ellsworth) County Medical Center and I actually have two questions.

Bill Finerfrock: Where's that located?

(Tina Davis): (Ellsworth), Kansas.

Bill Finerfrock: You're also Kansas.

(Tina Davis): Yes.

Bill Finerfrock: OK.

(Tina Davis): On consent forms, we have patients that come in weekly for injections of Vitamin B or their allergy shots. Do we need to obtain a consent form each time?

BethAnn Perkins: I would say no on those, I mean, and actually just basic injections, you know, you have to look at applying invasive - the descriptive of invasive and I think in that situation if that's something that your organization requires then I would define that a consent for the purposes of Vitamin B injection or allergy injections is good for six months or I would define it.

(Tina Davis): OK, thank you, and my second question is you had suggested that our nursing staff when they complete their documentation that they print their name and then sign it.

BethAnn Perkins: No, no, no, no. What I'm saying is that the standard of care (is) moving towards in nursing that the documentation itself is printed.

(Tina Davis): OK.

BethAnn Perkins: So when you say, you know, patient presents for evaluation of medication management, that's printed, but then (B) Perkins, RN, is signed.

(Tina Davis): OK, thank you.

Operator: And we'll take our next question.

Bill Finerfrock: Go ahead, caller.

(Charlene): Yes, this is (Charlene). I'm in eastern Montana at a rural health clinic and we've just gone to a EMR so we are all trying to learn the program. Do you have any tips for us as far as things we need to keep in mind?

BethAnn Perkins: EMR, are you right now transitioning from paper - from a paper environment to an EMR?

(Charlene): Right.

BethAnn Perkins: And so at times, you are still operating in that paper environment because there's only so many hours in the day?

(Charlene): Well, mostly, it's because something in the system doesn't work right.

BethAnn Perkins: OK, what I'm - what I'm finding for those clinics that are in transition is that people are starting to get so used to some of the bells and whistles with EMRs and how they crosswalk information into medication flow sheet or into a growth chart or into, and other aspects of the record immunizations that when they are operating in the paper environment they forget that and they omit documentation.

So my first tip would be, while you're still operating in the paper environment be very aware and be very cognizant that those bells and whistles that are happening in the electronic world do not function in paper and you just can't omit them and use the excuse but we're transitioning right now into an EMR because, you know, that information is lost with that.

The second thing I would just caution is that again in a lot of EMRS that templates are set up and understand that, you know, you have to hit one field before you can go onto the next, but you still have to be accurate if you do a review of systems and you just hit every system, then you better make sure you've reviewed every system and not just hit the button because that's what you were accustomed to doing in a paper template. So that's what I'm seeing; I'm seeing that providers are taking some of those bad habits and bringing them over into the EMR, and, the EMR, is not full proof.

(Charlene): Yes, yes. Well, that was one of my concerns with templates. Because every patient's a little different, I look at these templates as being somewhat of a hindrance because now I have not personalized this person. I've just put them into a same cookie cutter record (of) somebody else.

BethAnn Perkins: Right and a lot of times you'll have pre-populated language or verbiage for an abnormal, and as you suggested, we're all unique individuals and that doesn't always work. And what happens is that oftentimes just providers get caught up into the day-to-day of seeing patients and they don't stop and make those adjustments and so that is unique to that patient and it really speaks to - it's very descriptive of what that patient is experiencing.
So I think in your review that's something that you have to be very cognizant of.

(Charlene): … end up typing out the information rather than (picking) the template because they maybe don't have the right description of . . .

BethAnn Perkins: Right.

(Charlene): . . . of the situation like the templates adjustment. No, that's just not it so I end up typing and then that takes time.

BethAnn Perkins: (Well) - and I've had some that have gone to actually laying voice recognition over that so that they can voice in, to help slow that (down), or speed that up, rather.

(Charlene): Yes, at this point they're not doing that (or ) . . .

Bill Finerfrock: (We) need to move on to the next question if we could.

Female: Sure.

Bill Finerfrock: Thank you, (Charlene).

(Charlene): OK, thanks.

Operator: And we'll take our next question at this time.

Bill Finerfrock: Go ahead, caller.

Operator: Caller, your line is open. Please go ahead. Caller, your line is open. Please go ahead.

Hearing no response, we'll take our next question.

Bill Finerfrock: Go ahead.

(Mary Peterson): (Mary Peterson), ((inaudible)) Clinic, (Boston), Wisconsin. I have a question. You mentioned that the gauge of the needle should be mentioned with an injection. Is that something - what's the relevancy of that?

BethAnn Perkins: Well, the relevancy of that is if there is any complications as it relates to the site of the injection. So making sure that again staff is aware, you know, it's a 21-gauge needle that was used for the injection and it was a 23-gauge butterfly. So, you know, it is being as descriptive as possible in the event that there is a reaction or there's anything untoward that occurred as a result. And that's just really standard in nursing. That's just standard nursing practice.

(Mary Peterson): And I guess I - one other question. You talked a lot about prescriptions . . .

BethAnn Perkins: Right.

(Mary Peterson): . . . and I know we in Wisconsin as well as all states in the nation have to be engaged in temper-resistant prescription pads and when you're out auditing are you looking for that type of thing also?

BethAnn Perkins: I am.

(Mary Peterson): Oh, I guess we're perplexed because, you know, one of the measures is one or more industry recognized features is ((inaudible)) the erasure or modification of information written on the prescription by the prescriber. Are you familiar with those types of pads? Have you seen that out there?

BethAnn Perkins: I have not seen those out there yet. Most of what I'm seeing people are (using up) with have been preprinted and with that but I have not seen those and I will let you know as soon as I do start seeing stuff like that. You know, I'd be happy to share that with Bill to make that available with everybody . . .

(Mary Peterson): That would be good because it would come under the Medicaid part of our rural health and, you know, we're - I'm out there on Google trying to find things and we do find, you know, erasure proof paper or whatever but the - you know, how you would stop the modifying of 10 - you know, from going into a 40 mgs versus 10.

BethAnn Perkins: Right, exactly. And like I said, you know, I have the opportunity to - and the privilege to be in clinics across the country and in health systems across the country and sometimes, you know, I do uncover those pearls and when I come across it I, you know, definitely will share it with the organization.

(Mary Peterson): That'd be great. I (don't) know surveyors are going to take that up, you know, looking for that temper-resistant paper (or not) but . . .

BethAnn Perkins: At some point and sometimes it depends on your surveyor, you know, and how it just - it's kind of like the flavor of the month.

(Mary Peterson): OK, thanks.

Bill Finerfrock: Next caller?

Operator: And Mr. Finerfrock, we have no additional questions at this time.

Bill Finerfrock: OK, at that point then I'd like to thank BethAnn for the time she took to present with us today. There will be a - both an audio transcript or audio recording of this call made available and it will be posted on the RHC Web site along with a written transcript of today's call so that if you want to go back and relisten to it or look at the transcript or you have a colleague that you think might benefit from listening to this presentation who wasn't able to make it they can go back and hear that call.

Our next call will be in two months. It will be the - scheduled for the second Tuesday in November at 2:00. We don't have the subject yet but that will be announced relatively soon. We look forward to your participation in that call.

Once again, we want to thank the office of Rural Health Policy for supporting this initiative. We hope that you found it helpful today and in particular we want to thank our speaker today, BethAnn Perkins, for the valuable information she shared with us. Thank you for being here and that concludes today's call.

BethAnn, could you stay on the line?

BethAnn Perkins: Yes.

Operator: And thank you. This does conclude our conference call for today. We thank you for your participation and have a great afternoon.

END

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