Weighing In – A Necessary Evil

By Janice Jacobs, CPA, CPC, CCS, CPCO, ROCC
No one wants to get on the scale at the doctor’s office and, while we all cringe at seeing the needle go in the wrong direction, this important step can be critical in the coordination and care of a patient. A medical assistant recently greeted a new patient in the waiting room and took her back to get her height, weight, blood pressure, and temperature, as well as some preliminary information. With all good intentions, she attempted to make small talk to put the patient at ease on her first visit. In the exam room, as she began entering the information into the computer, she realized that because of the casual conversation, she was distracted as she performed her tasks. She not only didn’t document the patient’s weight while she was on the scale, but forgot the actual number. Instead of apologizing and taking the patient back to be re-weighed, she simply asked the patient whether she remembered what the scale said and mentioned a weight that she thought was right but was actually much lower. The patient laughed and said that sounded good to her and into the electronic medical record it went to be documented as a permanent part of this patient’s history.
During the evaluation and management by the physician, it was noted that the patient just started hormone replacement therapy (HRT) with her gynecologist only two days prior and one of her primary concerns with this treatment was the potential side effect of weight gain. The doctor advised her that, in her case, the benefits outweighed the risks and that he’d monitor her closely to make sure any unusual weight gain was assessed and her medication dosage adjusted accordingly. However, the patient’s EMR reflected the wrong weight from her first date of service and reassessment of her HRT therapy at a future point in time will be based upon the incorrect starting weight resulting in the possibility of her medication being adjusted inappropriately or stopped completely.
Accurate capture of vital information is imperative to quality and proper coordination of care. The medical assistant should have weighed the patient again and risk a minor inconvenience rather than a serious health issue down in the future. Practice managers must educate all staff involved in data collection so that they fully understand the long-term ramifications to the patient of an oversight such as this.

Janice Jacobs

About Has 5 Posts

Janice G. Jacobs, CPC, CPCO, is a Director at IMA Consulting in their Compliance and Coding Practice. Janice has over 25 years of healthcare industry experience including hospital accounting and auditing, inpatient, outpatient and professional fee coding, compliance, and revenue cycle management. Janice frequently advises large physician practices on various coding and compliance issues.

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