The United States Department of Health and Human Services Office of Inspector
General recently completed an audit of inpatient services at BWH and concluded that medical records did not contain documentation of all practitioners’ orders. As a result, BWH was compelled to refund monies to Medicare. Our participation in the Medicare Program and our internal policies require that all services provided are appropriately
documented in the medical record in accordance with standards of practice and Medicare laws and regulations. The following is a reminder of provider responsibilities under the Hospital’s Medical Record Guidelines.
BWH Documentation Responsibilities and rules
A. Record Completion Responsibility
Completion of the medical record is the responsibility of the attending physician.
B. General Documentation Rules
- Write, print or imprint the patient name and medical record number on the front and back of every page.
- Time and date all entries.
- Authenticate by signing (via computer key or pen) any verbal or telephone order within 24 hours.
- Authenticate ("sign") each entry and include the professional title and clinician identification number.
- Entries must be permanent and capable of being copied.
- Make entries which are accurate, timely, comprehensive and reflective of thought processes.
- Use only abbreviations and symbols approved by the medical staff. The approved list is in the Administrative Policy Manual, on-line in BICS/Utilities/Administrative Manual/#7 Administrative Policies.
- Correct:
- A paper entry by drawing a line through it, labeling it “error”, writing the new entry, signing it and dating it. NEVER use whiteout or try to obliterate an entry;
- A computer entry by entering “Miscellaneous” order to describe error using computer generated “order #” as reference and/or D/C the order and add note as to error.
If you have any questions about these guidelines please contact Jackie Raymond at ext. 2-6068.