A topic that comes up many times is the subject of recording negative findings in one’s medical records. I would like a nickel for every time a client states that they only record positive findings. Say a patient denies an allergy to penicillin but it is not recorded. The patient is [...]
continue readingI review medical charts on a regular basis as part of my job. Many private offices still use handwritten charts. It is totally acceptable. However, what is not acceptable is illegible handwriting. A recent study showed more than 15% of all words written were illegible. This can result in mistakes in [...]
continue readingTo all medical providers who are now opened or are about to open, many states, including New York, require a written safety plan. Federally, a plan is required, but nothing is said about it being written or not. For your own protection, I suggest your plan be written. It need not [...]
continue readingIn New York, a written reopening safety plan is required. The CDC for the rest of the country refers to a “plan”. Best that it is written. It does not have to be submitted anywhere for approval. New York actually has a Safe Plan Template that is available for your free [...]
continue readingDo not forget OSHA requirements as to safety and cleanliness. Have staff go through all medications and samples to make sure usefulness date not expired. Have staff go through the dates of any sterilized instruments or garb. Re-sterilize and date as necessary. Check date on fire extinguisher. Check all dates on [...]
continue readingNow that many of you will be reopening your offices, here are a few reminders of best practices to protect both you and your patients: Make sure your charts include any and all telephone encounters with your patients during your physical closure. Make sure you have hand sanitizer readily available to [...]
continue readingNew York and many other states have a regulation which requires the licensed medical professional to report another licensed medical professional if it reasonably appears to show that a licensee is guilty of professional misconduct as defined in the particular state regulation or statute. Think about that! You see a colleague [...]
continue readingTelemedicine is not meant as a vehicle to increase your income during the COVID-19 pandemic. When you are performing a patient “visit” via telemedicine, if you are charging the government, the services must be medically necessary. Your chart must reflect the nature and reason of your “visit”. Your chart should document [...]
continue readingWe are all under tremendous pressure due to the Covid-19 Pandemic. However, you will not get a pass on patient follow-up care. You still must make patients aware of test results and their significance. You must still follow -up on proposed treatment plans. Follow-up on patient referrals is mandatory. Follow up [...]
continue readingLEGAL BRIEFS: CDC 101 The Center for Disease Control was founded after World War II. It grew out of an organization that helped fight malaria in war areas. It is part of the U.S. Public Health Services. It focuses on aspects of communicable diseases of all kinds as well as drug [...]
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