Articles Tagged With: Documentation
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Recommended Elements of a Compliance Program
Provider Relief Fund compliance will require an extensive and far-reaching program, experts note.
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The Basic Elements of Healthcare Reimbursement — Part 1
Changes in healthcare reimbursement have occurred with lightning speed over the last two decades. Providers billed for services rendered and were reimbursed — with no checks, balances, or control over costs of care. Case management, as a care delivery model, followed a similar course. But as reimbursement changed, so did case management. This month we will begin our discussion of reimbursement, including the changes to case management as it evolved with reimbursement.
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Specific Items, if Well-Documented, Prove ED Met EMTALA Obligations
When CMS surveyors come on site to investigate an EMTALA complaint, the outcome often comes down to documentation.
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Suspicious Changes to ED Chart Become Central Focus of Malpractice Lawsuit
Once someone concludes an emergency physician changed the medical record after a bad outcome, credibility (and likely the case) is lost. If there really is a valid reason to correct the electronic health record, clinicians should consult their facility’s policies and procedures regarding such corrections.
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Many Charts Lack Any Evidence of Thorough H&P
Often, a portion of the history, assessment, or evaluation was handled, but for whatever reason does not make it into the emergency medicine record. This makes it appear as though a poor or incomplete assessment was conducted. Double check these items to see they are included.
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Assessment, Documentation, and Protocols: All Tied to ED Malpractice Payouts
Malpractice claims are more likely to succeed if documentation is insufficient, if an assessment was inadequate, or if something was not handled according to policy or protocol.
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Simple Care, Concern Refute Perception of Bias that Fuels Lawsuits
It is not hard to imagine patients suspecting racial bias if they experience a rushed exam, long delays, or poor communication in the emergency department. Race is much more likely to become an issue if a provider behaves disrespectfully toward the patient.
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EMS Documentation Can Complicate Defense of ED Claim
Unpacking the various reasons why emergency medical service providers could become involved in emergency department malpractice lawsuits.
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Lawsuits Allege Negligent ED Care Caused Hospitalized Patient’s Poor Outcome
When emergency department patients are admitted but not yet transferred, that is a point of weakness for facilities.
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Wrong Box Checked in Chart? Common, Careless Error Complicates Defense
There are two types of discrepancies that can cause major problems for the defense during malpractice litigation. One, a discrepancy between the emergency physician's (EP) documentation and nursing documentation. Two, a discrepancy between the EP and obvious reality.