Looking Over Your Shoulder in Healthcare: Chart Audits

Part 2

Carolyn Buppert, NP, JD


December 08, 2011

In This Article

Editor's Note: Healthcare is serious business, and the repercussions of deficiencies in medical documentation can be considerable. In this 4-part series, nurse attorney Carolyn Buppert examines the landscape of medical record auditing and offers practical suggestions to improve your documentation. Part 2 reveals the identity of the "clipboard carriers" who might be examining your documentation.

Who Is Looking Over Your Shoulder?

The "who" in "who's looking over your shoulder?" can be the representative of any number of entities: payers, litigants' attorneys and experts, licensing boards, and accreditation organizations. Furthermore, in several states, the notes written by nurse practitioners (NPs) or physician assistants (PAs) are subject to an audit because of a requirement in those states that a physician review a percentage of progress notes generated by those clinicians. The physician's review must be documented, and licensing boards will audit compliance with this mandate. Some states (notably Alabama) have been checking for documentation of the oversight and disciplining physicians who fail to fulfill this requirement.

Each of the auditing groups -- payers, litigants, licensing boards, and accreditation organizations -- is looking for different things in the documentation. Payers want to determine whether the claim for reimbursement is justified. Litigants want to know whether a breach occurred in the standard of care. Licensing boards want to know whether the clinician acted within the scope of practice or was grossly negligent. Accreditation organizations want to ascertain that their standards and elements of performance have been met.


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