Friday, October 12, 2007

Templated Charting - The Slippery Slope to Fraudulant Documentation

The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and complained of neck, and leg pain. Our ED Physician came in and did his exam from the door way holding his Tablet PC marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupils and ocular movements, neuro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. I watched without comment throughout the day and noticed the same general exam pattern on most of his patients and the same comprehensive documentation of his exams. About one half of the Docs in this ED practice operate in a similar way although he is the worst. Others actually perform the exams they document and coincidental, have the longest door to provider times. They are being pressured to speed up their times. Exams do take time. This same Physician above is the promoter of Triage Bypass policy being promoted at the ED I work. He claims that asking patients the same questions and doing the same exam he will do (or not do) in Triage is an unnecessary delay and negatively effects patient satisfaction scores. So now when beds are open were rushing patients back with nothing more than an eyeball assessment to make them happy and get them to the Doctor who does a 1 minute exam from the doorway and fudges the chart. Guess what, our patient satisfaction numbers are way up and our length of stay is down. Administration is happy.

Fudging charting is not isolated to Physicians and Electronic Documentation. Another ED I occasionally work at I see nurses regularly check off on the paper T-Sheet items that were not done. I even see some make up phony discharge vital signs rather than take the time to do them. I recently had a discussion with my Charge Nurse who audits charts prior to the end of the shift. She was all over me because I was not checking off the boxes which said ID Band confirmed, Bed in low position, Side rails up x 2, patient gowned, blanket provided, and including discharge vitals. I told her, the patient was a Fast Track patient and discharged within minutes of arrival, I didn’t do all those things. Doesn’t matter she said, “Just check the boxes or we get dinged”. I told her to go ahead and ding me, make my day. I’d rather get dinged for not checking boxes than falsifying a chart. My stand is being viewed as I'm just being difficult.

The question that this begs is whether the problem is with the individuals or the tool. My opinion is a poorly designed tool facilitates shortcuts in certain individuals who are either lazy, dishonest, or very uninformed about what they are charting. Templated charting, either paper or electronic, can cross the line rapidly into fraudulent charting in those individuals. I don’t think they view it as fraud and are able to rationalize their actions because they feel they are only documenting to satisfy a regulatory requirement. In the case of documenting items not done to obtain a higher billing level there is no question in my mind that fraud is occurring.

A good article, here, at AIS list some of the issues with templated electronic documentation.

"Physicians love electronic medical record (EMR) templates because they make documentation faster and easier, but abuses, such as cloning and "exploding" notes, are jeopardizing reimbursement and compliance, experts say. If too much information is replicated from one EMR to the next, there is little to distinguish patient encounters, and that undermines physician attempts to establish medical necessity — the foundation of Medicare reimbursement — and perhaps implicates quality of care."

My first example I listed is an example of an exploding note. Basically, an electronic template is pulled up for a specific complaint, a few mouse clicks is all it takes to default all values to normal and a beautiful paragraph is produced based on programming code behind the scenes listing all the elements of a comprehensive normal exam. To change the defaults you need to click a few more times either selecting common abnormal values or free text the abnormal finding in. The path of least resistance is the former.

"Cloning can work for elements of the history, but cannot and should not be used for the history of present illness, the exam or the medical decision-making portion," the compliance officer says."

Cloning refers to pulling data forward from previous visits or from another persons note, usually via copy and paste, into your note and signing it as yours. Very helpful for a long history which does not change but problematic for a physical exam that you did not do. In Academic Medical Centers its common for the Student to do the exam, the Resident pulls forward the note as theirs and on rounds the Attending does the same and signs it electronically.

Templated charting both paper and electronic has caught the attention of many in the HIM community. The American Health Information Management Association has a good paper on Guidelines for EHR Documentation to prevent Fraud. The article list many types of documentation problems and recommendations and the appendix gives real case examples.

“Electronic documentation tools offer exciting new time-saving and validity checking features designed to enhance communication for all health record users. They address traditional, well-known requirements for documentation principles, while supporting expansive new HIM capabilities. However, use of these features without appropriate management and guidelines may cause invalid auto population of data fields, manufactured documentation to enhance expected reimbursement, and other undesirable outcomes”

What is the solution? It’s certainly not to stop using templated charting or electronic charting. It won’t be long before everyone is doing it. A strong set of standards for EMR design and training is essential. Charting tools that require structured data for most exam documentation would help. Rules against copying notes of others and calling them yours and the clear understanding that if you have charted something you did not do you have committed fraud. You can report fraud here. Templated charting, if used correctly, prompts the individual to perform complete exams and documentation and can enhance patient safety.


Weschtester Orthopedist said...

Nice post... i just posted an entry today why myself and my group will not enter the EMR arena for the forseeable future... tell me what you think.

Anonymous said...

ER Murse, could you email me regarding your Lyme disease comments on kevinmd's blog? I'm the medical writer for the San Jose Mercury News and would be interested in learning more for a possible story. I don't need to use your name. Thank you,
Barbara Feder Ostrov
Medical Writer
San Jose Mercury News

ndenunz said...

Excellent post. As the recipient of these reports I often wonder how much of the rather extensive exam is really done.
There was a time where, through a glitch in the template, a good portion of patients all had intact tracheostomy sites.

ERnursey said...

Another problem with the template charting is that every chart sounds the same....the patient was brought to the room, the IV was started, the patient was discharged. It is all generic and, unless the nurse is motivated enough to type in some notes, every chart sounds exactly the same as the other. As one colleague has found, that can be a real problem if you are brought to court.

Anonymous said...

I have lately started reading occupational blogs when eating dinner and a lot of them are medical because they are so very interesting. I have learned a lot: always, always, always mind your Ps and Qs in the ER and be kind to the staff and they will be kind to you. Always give good marks on the patient satisfaction form because if you don't, it causes a ridiculous amount of trouble for someone and probably doesn't actually accomplish anything. But now I have learned something else: if the doctor is using electronic records, find out how to see the records after your visit and see if anything in the records matches your recollection. I have a feeling that billing for things that weren't actually done probably constitutes some sort of fraud and will also make the insurance companies very unhappy.

MT of 20 Years said...

As someone whose job is being taken away daily, I completely understand the remarks made about templated charting. Being an MT (medical transcriptionist), we are seeing all that we hold holy being taken away. Patient care, patient safety, correct documentation, accurate reimbursements, correct information for coding and research... the list goes on.

Unfortunately, healthcare providers have been doing this for a long time. From the "use my standard template for the physical exam," to comatose dictating.

Unfortunately, there were several of our doctors who discovered the dangers in templates. One mistake caused a patient to recieve a medication to which he was allergic, and in a different case, the patient had obvious peritoneal signs on a physical exam, but his physician asked for a normal exam template.

I'm not sure what the solution is. Yes, there is pressure for patient satisfaction, there is a shortage of time to treat patients, and there is expense associated with documenting everything, but what it comes down to is patient care. Unfortunately, in the midst of a lawsuit, hindsight is 20/20.

Anonymous said...

Our recent JCAHO resulted in all templated notes with filled in data being prohibited. A templated note that had


now say


All findings have to be filled in. Now, nothing's to say the doc isn't going to fill in whatever he wants, but at least he's the one filling in the documentation, right or wrong. I guess it's a step in the right direction.

Onehealthpro said...

This is not only fraudulant, it is the height of unprofessionalism. Patients and family members are becoming wiser about health care quality issues and most no longer trust the advice given to them. Sad when health care professionals operate in this fashion...wait times may be down and that is pleasing, but when patients begin having problems related to poor assessments, they will forget all about how long it took to see a doctor and focus on the problems that were missed and/or created because they did see a doctor.

PE Mommy said...

Funny I had knee surgery last December. I never saw my surgeon that day. The nurses forgot about me because they got busy. No one remembered my iv till I got to the OR. Consents were signed by the PA in the office a week prior.

However, my operative report states that my surgeon reviewed all risks/benefits of the surgery. That my consents were signed the day of surgery and that he visited with me for any last minute questions. None of which happened the day of surgery as I never even saw him or the PA that day. Funny huh.

PeriopRN said...

Very interesting; Unfortunately I feel that in all areas of healthcare today, "fudging your charting" is encouraged and expected but yet kept a secret from the public. I am a Nurse who sees it every single day and in all areas where I've worked.

I feel the same way you do, pressured to document inaccurately or falsely because everybody wants everything faster and cheaper... I am afraid of being seen as difficult, and everyone thinks I care too much about this issue. I still try to remain firm and honest in a dishonest world.

If you have any inspiring updates or if you know of anything being done in this problem area, I'd be curious to hear from you. I'm going to take this nursing practice problem to Grad School and see what I can do with it. (I know it is definitely NOT only Nurses doing this, and many times we are pressured by Physicians to do things incorrectly, but I need a focus for my research.)

Wish me luck!
Periop RN

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