MOLOKAI OHANA HEALTH CARE, INC. Policy #: 02:004
POLICIES AND PROCEDURES Executive Director: ______
BOD:______
Effective Date: ______
CHART COMPLETION PENALTY POLICY
Purpose:
The purpose of this policy is to define penalties associated with delinquent records / patient encounters and /or documents.
Scope:
This policy covers all health care providers responsible for direct patient care or ancillary services who are permitted to document in the medical record.
Policy:
I. General:
1. Completed and signed medical records are essential to quality patient care as well as to compliance with state and federal billing and documentation regulations.
a. Record completion shall be monitored by the clinical directors, chief financial officer and executive director daily.
b. Providers must complete and sign off all records / patient encounters within 3 days of the patient visit.
c. Providers must respond and sign off on all documents on their EMR desktop within 5 days of receiving the document.
d. If a provider is on an extended leave of absence or vacation it is the provider responsibility to assign flags and documents to the provider in charge of the patient caseload or as designated by the Medical Director.
e. Vacation will NOT be approved in the event that records/ patient encounters and documents have not been completed as outlined above.
II. Delinquency:
1. If the provider has more then ten delinquent / incomplete records disciplinary penalties against the provider will be as follows:
a. First Delinquency:
i. The provider will receive a verbal warning from their supervisor.
ii. Mandatory PTO will be sanctioned against the provider until the records / patient encounters and documents have been completed and signed off.
b. Second Delinquency:
i. A note will be placed in the providers personnel file and documented in the annual performance evaluation.
ii. Mandatory PTO will be sanctioned against the provider until the records/ patient encounters and documents have been completed and signed off.
c. Third Delinquency:
i. Provider will enter into the Molokai Community Health Center Progressive Corrective Action policy at level 3 (suspension of three days without pay will occur giving the employee one last opportunity to correct the problem).
ii. Mandatory PTO will be sanctioned against the provider until the records / patient encounters and documents have been completed and signed off.
III. Permanent Delinquency
1. Documentation that remains incomplete due to health care provider departure, incapacitation or death will be filed “incomplete” permanently.
a. Records with unsigned documentation or entries will be forwarded to the clinical department director who will complete the following statement:
i. “incomplete: This patient’s care as documented was provided by (name of provider) who is no longer employed with this institution. I, ______(as relationship to the health care provider) am signing this document on behalf of (name of health care provider).”
b. Incomplete encounter will then be forwarded to the Medical Director. The following statement will be added to the record:
i. “incomplete: Due to the departure/death/or permanent incapacitation of the health care provider the ______report is unavailable and this record is being filed incomplete by order of the Medical Director ______Sign