Documentation Deficiency

Problem:

“We are concerned that in addition to potential clinical issues, our surgeon is deficient with respect to documentation. Will this be addressed by your reviewer? Are documentation deficiencies considered a deviation from standard of care?”

Solution:

When asked to conduct peer review, the challenge for our reviewers is to determine whether or not there were any deviations from the standard of care. Sometimes that is very difficult to do because the documentation is lacking, illegible or the physician’s rationale for treatment is missing. Such deficiencies are not only potential indicators for deficient care, but also present great challenges to others who depend upon the information contained in the record. Often times, both the medical care and the documentation represent quality of care issues. Other times, there may be ample evidence that the care appears appropriate, but the documentation is still lacking. Occasionally, the documentation is so deficient that the medical care cannot even be assessed. In any case, the risks of documentation deficiencies are great and therefore, when present, should be addressed by our reviewer. Separate from whether or not the medical standard of care was met, failure to adequately document is indeed a deviation from the standard of care.

As an independent peer review organization, MDReview physician reviewers strive to assess each case relative to standards of care. Despite the patient outcome, was the care appropriate? With respect to documentation, was it complete, thorough, legible and timely?

When the answer is no to either of these questions, the standard of care was not met. Ideally, each hospital’s medical staff has clearly delineated documentation requirements in its bylaws and policies and procedures. Aside from meeting regulatory and accreditation requirements, this ensures that the medical record can stand on its own in support of patient care and for retrospective peer review when needed. When documentation meets well accepted standards, peer review can focus more on the care and less on the quality of the documentation.

Inadequate documentation will lead our MDReview experts to identify documentation as failing to meet the standard, as a separate and distinct issue, even if the overall medical care is found to be satisfactory.