Cindy A. King RN, CPHQ, is assistant vice president of clinical, quality and compliance for Health Inventures.
Q: We have a physician in our ambulatory surgery center who refuses to document the date of service on her dictated operative reports. Is there any specific requirement for her to document the date of service on her dictated op reports?
Cindy King: According to the ASC CMS regulations (42 CFR 416.47 (Condition for Coverage: Medical Records)), it states that "The ASC must maintain complete, comprehensive and accurate medical records to ensure adequate patient care." Also, most accreditation organizations have standards that mandate the ASC maintain complete and accurate clinical records and that entries and/or paper-based records are authenticated by the author and dated accordingly, which could also demonstrate documented evidence for incorporating this information into the record in a timely manner. Additionally, from a community standard perspective, most facilities have corresponding medical record policies and procedures that address this type of detail, and lastly, whenever a practitioner applies and/or re-applies for medical staff privileges, there is usually verbiage included in the facility's medical staff bylaws and/or their attestation form on the application/re-application that they agree to abide by all of the ASC's policies and procedures.
Since the medical record is considered a legal document reflecting a patient's care, all entries of any kind — including reports — should be signed, dated and timed by the corresponding author on a consistent basis. This is, quite simply, good practice from a risk management perspective as well.
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If all else fails after having a one-on-one discussion with this physician and reviewing the facts listed above, then optimally I suggest that this individual be addressed by the facility's medical director as this type of concern might be considered a peer review issue and may need further review by other medical-quality leadership with recommendations forwarded to the governing board for a final decision/approval.
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