Fam Pract Manag. 2003 Feb;10(2):56.
Initialing medical record entries
Is a physician legally required to initial all dictation and medical reports he or she has reviewed? Should our practice have a policy in place that requires this?
Signing or initialing medical record entries is generally not required unless the physician, nurse or other provider created the entry in the record. However, in certain circumstances, such as when physicians provide verbal orders to nurses, federal law does require physicians and nurses to sign or initial the same entries in the record. Individual state laws may also encourage or require dual signatures in circumstances involving nonphysician providers, such as physician supervision of physician assistants. Contact your local attorney to find out what your state requires.
While a policy that requires initials or signatures on all entries reviewed would provide documentation to help support the medical decision-making process for coding and billing purposes, this type of documentation is not required by federal documentation guidelines. Having such a policy could be detrimental to physicians involved in audits or lawsuits, as it may lead third parties to assume that any entries or reports mistakenly not initialed or signed were not reviewed or considered by the physician in the medical decision-making process.
Group-visit consent forms
Do patients participating in group visits need to sign a consent form? If so, what should be included on the form?
At the first group visit, participants should sign and date a consent form that includes a confidentiality agreement and a medical waiver. Following are samples of each. Check the regulations in your organization and state to modify the text as needed.
Confidentiality agreement: “Because group visits involve patients disclosing private medical and social information, all participants in a group visit – including the patient and any accompanying family members – must agree to respect the privacy of all participants and keep their information confidential.
“By signing this confidentiality agreement, I assume the responsibility for keeping all information confidential.”
Medical waiver: “Payment for group visits is handled in the same manner as payment for traditional medical appointments. By participating in a group visit, patients assume responsibility for the cost of the medical services provided and any co-pays involved.
“By signing this form, I assume the responsibility of paying for my group-visit medical appointment and agree to pay any co-pays and all costs associated with this medical appointment.”
Click below to download a sample consent form. For more information on group visits, see “Planning Group Visits for High-Risk Patients,” FPM, June 2000, page 33.
Since so many of our patients are no-shows or late arrivals, we’re thinking of abolishing our appointment system altogether in favor of walk-ins. Is this a good idea?
No. Switching to an “appointmentless” system would be a big mistake for a couple of reasons. First, it’s probably not what your patients want. Most patients want (and all patients deserve) the respect and dignity of a scheduled appointment time. Second, no-shows and late arrivals are usually the result of faulty system design, not a character flaw in your patients. So instead of abolishing your appointment system, redesign it.
To reduce the number of no-shows, try the following strategies:
Reduce the delay between the time the patient calls for an appointment and the time the appointment actually occurs. “Same-day” appointments are a great way to do this. (See “Same-Day Appointments: Exploding the Access Paradigm,” September 2000, page 45.)
Give patients a reminder call prior to their visits. This takes relatively little time or effort and can help you capture revenue previously lost to no-shows.
Make cancellations easy, not difficult. If patients are put on hold as soon as they call your office, they won’t be inclined to notify you of cancellations.
Close the patient’s initial visit with clear, agreed-upon expectations. For example, if a patient requires a follow-up visit, stress the importance of showing up for that visit.
Call patients who do not show up for their appointments. Knowing your office will follow up with them, they may be less likely to do it again.
Make sure your schedulers follow a “script” when setting appointments. This will ensure that they ask all the right questions and give patients complete information regarding their appointments.
When it comes to reducing late arrivals in your practice, the best strategy is to be on time yourself. In many cases, we’ve “taught” patients to be late by being late ourselves.
Copyright © 2003 by the American Academy of Family Physicians.
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