1. One Word Change In CoP's Goes Into Effect This Week -- But It Will Expose Your Hospital To New EMTALA and Malpractice Risks

Buried deep within 22 pages of CoP regulatory changes that are scheduled to go into effect on January 26th is a one word change that will make a dramatic change in compliance requirements for Medicare, EMTALA, and possibly influence how your medical records will affect malpractice claims.

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.

CMS Comments:

"The timing of medical record entries is crucial for patient safety and quality of care. Timing applies to all medical record entries, not just to the authentication of verbal orders. This would include orders, progress notes, procedure notes, patient assessments, H&Ps, etc."

"Timing establishes when an order was given, when an activity, intervention, treatment, or procedure occurred, or when an activity, intervention, treatment or procedure is to take place. Timing and dating of entries establishes a baseline for future actions or assessments and establishes a timeline of events. Many patient interventions or assessments are based on time intervals or time lines of various signs, symptoms, or events."

"We proposed minor revisions that would clarify that all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form." -- Final Regulations (see www.medlaw.com for full text of all revisions)

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.

RISK MANAGERS:

Immediate policy and procedure reviews should be launched to assess your facility exposure. A medical records audit will typically demonstrate severe concern about compliance on this issue. Policy changes, staff education, and intense quality auditing will be required in most facilities.

ANOTHER IMPORTANT CHANGE:

The new federal standard for verification of verbal orders will also impact EMTALA compliance in the area of phone orders for transfers (including discharges in many OB triage areas) when a physician is not present.

The current rule indicates that the Qualified Medical Provider (typically RN or PA) may effect a transfer and sign the transfer certification after conferring with a physician by phone, if no physician is present. The rule requires that the physician must sign the order after the fact, but no specific time was specified.

Under the CoP change going into effect on Friday of this week, ALL verbal orders must be verified (electronic or manual signature) within 48 hours unless a state rule or law specifies a different length of time.

Some states have specific rules at this time which vary from 24 hours to 30 days. Those rules will not be changed by the CMS regulations. Those states without existing standards will be required to meet the federal standard unless and until they pass their own standard.

An interesting twist in the rule is that the actual person giving the verbal order does not have to validate the order -- partners, for instance, can sign the order for up to 5 years. The provision seems to anticipate that electronic systems will be fully in place by 2012.

CAUTION:

The EMTALA requirement for co-signature appears to mandate that the ACTUAL physician giving the verbal order for transfer MUST co-sign the transfer order created by the Qualified Medical Provider(QMP). I recommend that the hospital policy continue to require co-signature by the individual physician consulted by the QMP.