This week's problem is addressed by Herb Alexander, MD. A prominent orthopaedic surgeon, Dr. Alexander is a retired United States Navy Captain and has held numerous leadership roles throughout his distinguished Navy career and in private practice. Dr. Alexander remains active academically, lecturing nationally and internationally, and is a Principal of MDReview.
Problem:
"We are concerned that in addition to potential clinical issues, our surgeon is deficient with respect to documentation. Will this be addressed by your reviewer? Are documentation deficiencies considered a deviation from standard of care?"
Solution:
When asked
to conduct peer review, the challenge for our reviewers is to determine whether
or not there were any deviations from the standard of care. Sometimes that is very difficult to do because
the documentation is lacking, illegible, or the physician's rationale for
treatment is missing. Such deficiencies
are not only potential indicators for deficient care, but also present great
challenges to others who depend upon the information contained in the record. Often times, both the medical care and the documentation represent quality
of care issues. Other times, there may
be ample evidence that the care appears appropriate, but the documentation is still
lacking. Occasionally, the documentation
is so deficient that the medical care cannot even be assessed. In any case, the risks of documentation
deficiencies are great and therefore, when present, should be addressed by our
reviewer. Separate from whether or not
the medical standard of care was met, failure to adequately document is indeed
a deviation from the standard of care.
As an
independent peer review organization, MDReview physician reviewers strive to
assess each case relative to standards of care.
Despite the patient outcome, was the care appropriate? With respect to documentation, was it
complete, thorough, legible and timely? When
the answer is no to either of these questions, the standard of care was not
met. Ideally, each hospital's medical
staff has clearly delineated documentation requirements in its bylaws and
policies and procedures. Aside from
meeting regulatory and accreditation requirements, this insures that the
medical record can stand on its own in support of patient care and for
retrospective peer review when needed. When
documentation meets well accepted standards, peer review can focus more on the
care and less on the quality of the documentation.
Inadequate
documentation will lead our MDReview experts to identify documentation as
failing to meet the standard, as a separate and distinct issue, even if the
overall medical care is found to be satisfactory.
Tags:
Print
Send
Share
