Risk Management

A Message From Your Chair of the Board, Tamara R. Fountain, MD : Documentation

“It’s just words on a piece of paper!” This was the tearful response of my son, then 5, who had “graduated” from kindergarten and expecting a trophy or some other shiny hardware, had instead received an unframed computer-generated “diploma.” As he fought back bitter tears of disappointment (and I stifled a chuckle at the pomp of a kindergarten graduation in the first place), I hugged him close and tried to reassure him that some of the most important things in life are “words on a piece of paper.” Whether a birth certificate, medical license, or mortgage note, just about every important life event, achievement, or transaction is formalized with a document.

Words on paper (and increasingly, a computer screen) continue to be the primary method physicians use to record the patient encounter. When things go wrong, when there is a dispute, when answers are needed regarding a clinical outcome, the only reliable information available is what was documented in the medical record. One of the earliest tenets of risk management hammered into us during training is to document thoroughly and maintain the integrity of the medical record. “If it’s not in the record, it wasn’t done,” is a familiar plaintiff attorney refrain.

Failure to document, lost charts, medication errors, illegible entries, and altered records are examples of documentation deficiencies that have torpedoedan otherwise defensible OMIC malpractice claim. The migration of medical documentation to the electronic record is the solution, we are told, to most of what ails the paper record. Perhaps, but not necessarily. On the plus side, lost charts, illegible handwriting, and record alteration should be a thing of the past. On the minus side, with the click of a mouse, one can copy, paste, and propagate redundant, repetitive, and sometimes inaccurate data. In this issue of the Digest, we explore the state of medical record documentation to better harness the good parts of the electronic platform while avoiding its pitfalls.

Speaking of words on paper, we are excited about a project OMIC has entered into with the AAO’s Hoskins Center for Quality Eye Care. We are translating each of the consent forms on the OMIC website into Spanish. This will make our internationally recognized library of ophthalmic consent forms available to a broader audience.

Our insureds spoke; we listened. While already permitting immediate sequential bilateral cataract extraction, OMIC has modified its underwriting requirements to allow immediate sequential bilateral intraocular refractive surgery. With appropriate guidelines and proper informed consent, insureds may now offer this option to patients seeking same-day bilateral refractive lens extraction.

Finally, every five years, our financial statements and overall corporate governance are reviewed by auditors from our domicile state of Vermont. I am happy to report that OMIC received the top rating on its internal financials and controls and was placed in the top compliance tier of the nation’s physician insurers. More good words on paper!

As for that tearful kindergartner, his college graduation was a few weeks ago. The setting may have been different, but many things were the same. There was pomp, circumstance, and more words on a piece of paper, and again some tears. This time, however, the tears were mine.

Tamara R. Fountain, MD, Chair of the Board