This week, probably for the 1,000th time, I struggled during my review of a complicated medical chart to determine exactly when certain events occurred in a hospital stay. When was my client taken off oxygen? When did the nurse escort him to the bathroom? The times mattered greatly because my client died of an undiagnosed pneumonia shortly after his discharge from the hospital.
Although many events in a hospital record are specifically timed, others are not. They just happened and that’s that. Take our word for it, seems to be the message. And, they were done at the right time.
Well, times they are a-changin’.
TIME — The New Documentation Trap
Most risk managers have pushed for timed-entries in the medical record to help document sequence and timeliness of care. Often EMTALA and other compliance issues hinge on the time of various entries — but most hospitals that have not gone to electronic medical records have very few timed entries.
Starting this Friday, EVERY entry in the medical record MUST be timed.
At MedLaw.com comes this WARNING:
The first applications of this rule are likely to be encountered in EMTALA investigations in the “Dedicated Emergency Departments” of a hospital — typically, ED, OB, Psych, Urgent Care, etc. CMS has always focused very closely on times, and the lack of timed entries will now be a potential STANDARDS LEVEL violation for medical records that could mushroom into an EMTALA 21 Day Notice of Termination (EMTALA citation).
On the Medical Malpractice side, ambiguities in treatment records caused by lack of timed entries might be fodder for Plaintiffs attack on the record’s accuracy.
Yeah, I confess, it would be nice to be able to tell when my client’s oxygen was discontinued.