Over 8,000 unlocked medical records

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I am hoping someone can give me some advice. I am a medical coder for a small 1 physician practice. In 2014, we switched over to new Practice Management software for EHR. I have been educating, prodding, advising both Dr and the Office Manager regarding the seriousness of locking medical records. There is a strict protocol in place by the Office Manager that NO records are EVER to be locked by ANYONE, in case "changes need to be made". After 2 years, it is clear to me that every effort I have made, every article, every warning regarding compliance has fallen on deaf ears. I ran a report this morning, and from 2015 to present, there are over 8,000 unlocked electronic medical records. Does anyone have any advice on what I should do?
 

mhstrauss

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I am hoping someone can give me some advice. I am a medical coder for a small 1 physician practice. In 2014, we switched over to new Practice Management software for EHR. I have been educating, prodding, advising both Dr and the Office Manager regarding the seriousness of locking medical records. There is a strict protocol in place by the Office Manager that NO records are EVER to be locked by ANYONE, in case "changes need to be made". After 2 years, it is clear to me that every effort I have made, every article, every warning regarding compliance has fallen on deaf ears. I ran a report this morning, and from 2015 to present, there are over 8,000 unlocked electronic medical records. Does anyone have any advice on what I should do?

I just want to clarify, because we use different verbiage for our EHR...by "locked", do you mean signed? As in, the provider performs an office visit or other service, but never signs off on it? That leaves it open for pretty much any one to make changes to the document, after the claim is filed! I know that is a big fat NO-NO, and I'm pretty sure it's been discussed here. Will try to find some info to post.
 
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Unsigned AND unlocked

The answer to your question is both unsigned AND unlocked. Dr refuses to create a digital signature, and yes, the records are open and free to be changed by ANYONE, at any given time. ALL charting and documentation is done by the techs....uncertified, no medical background or training. (I work for an Ophthalmic Surgeon).
 

mitchellde

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The problem is big and unending with this. A claim should never be sent until the document is signed. Addendums cannot be added once the claim has been sent. You are risking the payers auditing any one record and then requesting refunds for all that were submitted. Every time an electronic record is accessed a date and time stamp is added by the system. You will show a claim date way before the record was finalized. Thus is an auditing nightmare and there may be no way to fix it.
 
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Auditing

Thank you for your response. I do understand all of this, and I have repeatedly shared all of this, with documentation from CMS, supporting my concerns; I do not know if Dr thinks that he is above this, or if he is too small of a practice for this to be of any concern.

As we are all in agreement that this is wrong, on so many levels, what are my options at this point? I understand that my knowledge of these actions makes me culpable, as well. I have been searching for other employment, as I do not want to put my own career at risk. I have had hopes that eventually, my pleas would be met with a desire to rectify this situation. After 2 years, it is clear to me that it's just not going to happen.

What are your recommendations? Do I quit? Do I report him? What are my options without blackballing myself, or setting my own self up for a whole lot of legal issues of my own?

Some heartfelt, direct advice would be greatly appreciated.
 

mitchellde

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Thank you for your response. I do understand all of this, and I have repeatedly shared all of this, with documentation from CMS, supporting my concerns; I do not know if Dr thinks that he is above this, or if he is too small of a practice for this to be of any concern.

As we are all in agreement that this is wrong, on so many levels, what are my options at this point? I understand that my knowledge of these actions makes me culpable, as well. I have been searching for other employment, as I do not want to put my own career at risk. I have had hopes that eventually, my pleas would be met with a desire to rectify this situation. After 2 years, it is clear to me that it's just not going to happen.

What are your recommendations? Do I quit? Do I report him? What are my options without blackballing myself, or setting my own self up for a whole lot of legal issues of my own?

Some heartfelt, direct advice would be greatly appreciated.
There was an article many years back in The Coding Edge written by an attorney that stated if you knew of a wrong doing and attempts to correct it failed then you have a duty to report it to the authorities. Your failure to report it make you equally liable for the action. You may want to contact an attorney that has experience with health care compliance. Most reputable attorneys will give a free consultation. You can also contact the attorney general in your state.
 

thomas7331

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This was actually discussed this week in the legal session at Healthcon in Orlando. If I understood the expert who spoke correctly, the fact that a record is not signed is not such a serious compliance problem as long as there is an audit trail that shows the documentation was done contemporaneously with the performance of the service. He mentioned that there is an attestation process that can be done in the event that an unsigned record is requested during an audit. The compliance issue occurs when the records are left open for the purpose of editing them after the fact in order to inappropriately manipulate them for billing/reimbursement purposes.

Again, I'm paraphrasing what I heard, and probably not very well, but I definitely agree that this is something that a lawyer with a thorough understanding of these regulations should review for you. As the disclaimers all over this forum state, the posts here should not be taken as legal advice for your particular situation.
 

cfitzgibbons

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The answer to your question is both unsigned AND unlocked. Dr refuses to create a digital signature, and yes, the records are open and free to be changed by ANYONE, at any given time. ALL charting and documentation is done by the techs....uncertified, no medical background or training. (I work for an Ophthalmic Surgeon).

I would think that not signing and locking these, it would leave the provider open to a wide range of issues. And especially, if someone else comes along and alters these records.

This is just in my humble opinion.

Colleen Fitzgibbons, B.A., C.P.C.
 
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I have a question regarding who can and can not lock medical charts in a EHR/EMR.

The providers will do all their documentation and sign and date the chart, but who can lock a chart? Does it have to be the provider that saw that patient or can it be anyone in the practice?
Any help or direction would be great!

Thanks,
Lauren McElhaney, CPC, CPB
 

csperoni

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I have a question regarding who can and can not lock medical charts in a EHR/EMR.

The providers will do all their documentation and sign and date the chart, but who can lock a chart? Does it have to be the provider that saw that patient or can it be anyone in the practice?
Any help or direction would be great!

Thanks,
Lauren McElhaney, CPC, CPB
I'm not certain what the difference in your system is between "locking a chart" other than signed by the provider. In the 3 systems I've used, there is no separate locking.
Before signed by provider, any clinical staff with privileges may add/edit/delete info.
Once it's signed by the provider, it's complete and changes cannot be made unless you are creating an addendum, and the provider would need to sign again.
 
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We are using ECW eClinical Works and the provider can sign the chart without it being closed. If the chart is signed but not closed the status shows pending.
Are there any regulations that state that another user can not close the chart?
 
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Actually I just spoke with our Technical department with this EHR and the provider has to be the one to lock the chart since the person that locks the chart will be the person that the system will accept to sign the chart.
If prior to the provider locking the chart and just signs the chart, is it ok to bill with just having the chart signed but not locked?
 

csperoni

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Actually I just spoke with our Technical department with this EHR and the provider has to be the one to lock the chart since the person that locks the chart will be the person that the system will accept to sign the chart.
If prior to the provider locking the chart and just signs the chart, is it ok to bill with just having the chart signed but not locked?
As long as it is signed and complete, I would not have an issue with billing it. I don't know ECW at all to understand exactly what happens when the provider "locks" the chart. It seems like a redundant step if the provider has to sign AND lock.
If the note is not considered complete until locked, then I would not submit billing until complete (locked).
 
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