Insights From Wapiti

The following article is from the MagMutual Learning center. MagMutual, an A rated healthcare liability insurance company, is the malpractice insurance carrier used by Wapiti Medical Staffing. 

Organizations are occasionally faced with the immediate termination or abrupt departure of a physician or licensed clinician (“departed physician”).  When that happens, there may be open, incomplete charts left behind.  It is important to take immediate steps to complete those charts for patient safety, continuity of care, and billing purposes. This guidance focuses on ensuring the charts are appropriate for reimbursement submissions.

In order to properly submit a claim for reimbursement, the patient’s medical record encounter must be “closed” and include a valid physician signature. It is likely that a departed physician will have open medical records that are not “closed,” and thus the open medical record encounter does not include the populated physician signature required for billing. A valid signature authenticates the service and is handwritten or electronically signed. There are two main options available to organizations when they are left with open charts.

Option 1: Obtain Attestation from the Departed Physician

The organization should attempt to have the departed physician attest to the medical record(s). The departed physician’s attestation will stand in place of a physical signature. The attestation should be dated and signed by the departed physician, and the document should contain sufficient information to identify the patient. The departed physician will need to include accurate, true, and complete information regarding the treatment or diagnosis of the patient. If the departed physician is willing to attest to the medical record, the medical record may be closed and the practice may bill for the service provided under the departed physician’s billing information. For illustrative purposes, the following sample attestation would be valid.

“I, [full name of the physician/practitioner], hereby attest that the medical record entry for [date of service] accurately reflects signatures/notations that I made in my capacity as [provider credentials, e.g., M.D.] when I treated/diagnosed the above-listed patient. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

Though the medical record has properly been closed for patients treated by the departed physician, the organization should remain aware of the patient’s medical care needs. The organization should have an internal protocol to transfer the patient to another provider to ensure ongoing care, inform the patient about diagnoses and lab results, continue to prescribe medication, etc. A strong internal protocol with respect to appropriately transitioning patients and ensuring continuity of care can help limit liability for the practice with respect to claims such as patient abandonment and delay in diagnosis.

Option 2: Another Physician Should Appropriately Close the Encounter

If the departed physician is not willing to attest to the medical record(s), another physician in the organization may access the medical record and take the appropriate steps to close the medical record. The new physician may need to include pertinent amendments, corrections, or addenda to the medical record before the medical record may be properly closed. These alterations should be clearly and permanently documented with the new physician dating and signing the medical record and utilizing the new physician’s billing information. The original content created by the terminated physician should not be deleted in any way. In dealing specifically with electronic medical records, corrections should provide a reliable means to identify the original work by the terminated physician, the new content, and the date and author of each entry. The practice may now bill for the services rendered or ordered with the new physician’s signature and billing information … continue reading