Question

You are the director of health information service at a tertiary care hospital. You and the director of emergency room services are jointly responsible for reporting instances of communicable disease, child abuse, and cancer to the appropriate state authority. You have just completed an audit of your institution's reporting and discovered that the reporting requirements are not consistently met. The audit could not definitively establish whether the reporting never occurred or occurred but was not documented in the patient's health record. Discuss what legal issues are present and what approaches you should take to resolve this problem.

Answer 1

Some of the legal issues which are present here are

• wrong coding or no coding of medical services can lead to financial drawbacks to the government
• Submission of records will be impossible by the healthcare organizations, if a patient claims legally in the court for any medical services received by them in an unsatisfactory way
• The continuity of the care may be hampered
• The organisation can be even sued for their license in case of these types of practices.
• No proper documentation always indicates some sort of medical malpractice or negligence
• The organisation can be cancelled for license when the standards are not met
• The professionals not responsible for documentation can be given a memo or a notice

The ways to resolve them are

• Encouraging and making compulsory requirements for documentation to be done by the professionals or actions will be taken on them
• a continuous education program on this topic can give them brief idea to handle it
• Regular updation and follow up to be done by the HIM director