Pateint complaints

jacob1862

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We were recently asked if patient complaints can be added to the patient's medical record, what I have seen is the clinical staff will add a phone note stating patient was upset and complaint was forwarded to a manager or provider, should they be adding the complaint in the record or tracking them on a separate log?
 

Chelle-Lynn

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It would depend on the nature of the compliant. If it was in regards to a billing issue, then this would not necessarily be added to the patients chart. However if the concern addressed was in regards to the care they received then it may be appropriate.

In general you would need to work with your office Compliance Officer to set up a consistent policy and process for logging these concerns or compliants. You would want to make sure that the concern is reviewed for any type of issue that may need to be escalated to the compliance officer for additional follow up. You would definitely want to address what type of documentation is needed and where it should be kept (log, file, etc). In addition the log or file would need to clearly show any steps taken to address the concern, your communication with the patient, and the final outcome.
 
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I also agree that it depends on the situation. If it's just a general billing issue, for example a patient is upset over a bill they received (usually it's about a high deductible), it doesn't really belong in the patient's record per se. In the facility I work at, we direct our staff to note the account (similar to a phone note I suppose) detailing the interaction and what was done to resolve the problem. Mostly it's for documentation purposes. However, if the patient complaint is directed back to the billing staff, say to review the coding, they will document that in the patient's record; and the referring staff member will also put up a note on the account.
 
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