Missing signatures

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Fines From Missing Signatures - Forms in Medical Supply or Hospitals

Although we were unable to identify some examples of the variety of fines administered solely for missing signatures on forms, we found a few consequences of incomplete medical documentation. Physicians can be fined for maintaining inadequate records. It can result in unpaid services from the Centers for Medicare & Medicaid Services. Improper record keeping, including missing signatures, can also lead to lawsuits from patients. Moreover, missing documentation can be utilized by prosecutors in malpractice suits. Below we have presented a detailed overview of our research strategy, along with the relevant findings of our research.

METHODOLOGY

We began our research by examining government and legal sources for information on the types of fines that could be produced from missing signatures on forms in medical supply channels or hospitals. Though we could not locate specific information on missing signatures, we found data on incomplete documentation overall. Since an absent signature on a form or medical record could be deemed incomplete, we elected to broaden our research to concentrate on incomplete\inadequate medical documentation. We discovered some samples of real fines inflicted for inadequate documentation, but could not find the types of penalties for incomplete documents specifically. Nevertheless, after reviewing court cases, we discovered that incomplete documentation does not appear to have numerous examples regarding legal ramifications, but it can impact a provider's credibility if they are associated with a malpractice suit.

We then expanded our research to incorporate cases for medical malpractice and observed some examples involving incomplete documentation. Additionally, we found an article from a scientific journal discussing how incomplete documentation can directly influence the metrics administered in the value-based healthcare system. We regarded this information suitable for this particular request as low provider metrics typically lead to a lower reimbursement of funds. Afterward, we began exploring for additional data, as well as cases of incomplete documentation impacting pay-for-performance (P4P) and value-based systems. Although we came across a report on P4P operations and clinical documentation development, it was behind a paywall. Nevertheless, an excerpt of the article provided an overview of some of its details, which we included in this report.

INADEQUATE DOCUMENTATION

There was a court case involving a physician accused of dishonoring the standard of care and preserving inadequate records for three different patients. He was ordered to pay a $1,000 fine, and to attend sessions on record keeping. Another court case involved a physician who was placed on probation because of incompetent record keeping.

UNPAID SERVICES

The Centers for Medicare & Medicaid Services (CMS) can deny cases if documentation is inadequate, including for missing signatures. For example, the CMS rejected about $48,789,786 in government funding for the Medicaid program in Pennsylvania due to deficient documentation, including absent signatures. Furthermore, if a provider's notes are unreadable or incomplete, a medical biller may have trouble paying claims and they may decide to return as a result. Also, patients can observe their medical records, and if they notice any mistakes, they could file a lawsuit. In situations where treatment was suitable, but was documented inaccurately, providers could drop a patient's bill to evade a legal case.

MALPRACTICE CLAIMS

According to MedPro, complete documentation could have supported a doctor's defense in a case where their decisions were disputed following a patient's death. In another example, a nursing facility was sued for wrongful death and medical malpractice because of inaccurate record keeping, as well as neglecting to document critical changes in the patient. While incomplete medical documentation by itself is not the basis for malpractice suits, they are suggestive of second-rate care.

ADDITIONAL EFFECT - PAY FOR PERFORMANCE LANDSCAPE

Healthcare is swiftly converting into a pay for performance (value-based) system, as quality metrics are considered during the reimbursement process. Unfinished medical documentation not only indicates noncompliance to standards, but it can lead to lower metrics. Also, adequate and comprehensive physician notes are needed for efficient medical coding. Suitable medical coding influences pay for performance applications and adjustments.
Sources
Sources

Quotes
  • "Hall's notes for both patients were "incomplete, illegible and wholly lacking in required information."
Quotes
  • "Careful documentation of each patient's condition and the factors that went into determining the diagnosis, combined with thorough post-treatment investigation of unanticipated outcomes, may help support the defense of a potential malpractice claim."
Quotes
  • "Relevant to this case is 42 C.F.R. §483.75(l), which pertains to clinical records: “(1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are — (i) complete; (ii) accurately documented; (iii) readily accessible; and (iv) systematically organized.”"
Quotes
  • " Reviewers also place claims into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety."
Quotes
  • "If a provider has provided incorrect, illegible, or incomplete documentation of a procedure or patient visit, it’s difficult to make an accurate or complete claim."
Quotes
  • "The poorly kept record is not, in itself, proof of negligence on the part of the health care provider; but it is proof of substandard care."
  • "While courts and juries usually give a physician the benefit of the doubt on ambiguous matters, this does not extend to ambiguities created by incompetent record keeping."
Quotes
  • "As health care moves slowly but inexorably into a pay for performance landscape, the ability of institutions to respond to quality metrics becomes increasingly important. Quality of care and performance of clinicians are already, albeit unevenly, beginning to be evaluated on the basis of conformance to standardized recommendations, such as those articulated through quality metrics and evidence-based clinical practice guidelines."
  • "If quality is only assessed when complete data are available (as is currently done), then reported performance on quality metrics likely does not represent quality of actual care. Because patients included will be those whose medical records reflect the best documentation—and hence will be those who are most likely to be receiving best care—reported performance is likely to be inflated. "
Quotes
  • "The February 2014 report noted the following “examples” of documentation deficiencies: “(1) timesheets [of the service provider] not signed by the recipient of services, (2) timesheets not supporting the hours claimed, (3) no service order detail to indicate the types of services to be performed, (4) time sheets not demonstrating what services were conducted and other information provided did not demonstrate services provided, and (5) no documentation provided at all.""
Quotes
  • "Because many of the P4P measures are claims based, meaning the performance for claims-based measures is derived from diagnosis codes submitted on claims."