TEXAS MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution 415 (A-07)
Subject: Medical Record Completion Standards Compliance
Introduced by: Travis County Medical Society
Referred to: Reference Committee on Socioeconomics
Whereas, All physicians and hospitals should strive for clinical excellence, including appropriate and timely documentation; and
Whereas, Timely completion of medical records is a professional requirement for all physicians; and
Whereas, A long-standing Centers for Medicare & Medicaid Services (CMS) rule requires that hospital medical records be completed within 30 days of discharge; and
Whereas, All hospitals track the percentage of completed medical records as a quality measure and encourage physicians to meet this 30-day standard to the greatest extent possible; and
Whereas, Because other departments and staff members often use hospital charts for documentation concurrently with physicians, and because charts often are used in the immediate 30 days after discharge in other hospital settings (such as for procedures, diagnostics, or treatment in hospital-based specialty clinics), it is difficult for multiple physicians and staff members to have access to all their medical records when they attempt to complete available records; and
Whereas, Many of these situations make it logistically impossible and unrealistic to complete 100 percent of the records all of the time within 30 days until such time that comprehensive, universally-utilized electronic medical records (EMRs) make this potentially feasible; and
Whereas, A recent CMS interpretation, enforced by the Texas Department of State Health Services, requires hospitals to demonstrate compliance rates of 100 percent chart completion within 30 days or face significant fines and initiation of the Medicare 90-day termination track; and
Whereas, This level of compliance has created a de facto unfunded mandate for additional staffing and/or the purchase of EMRs in hospitals; therefore be it
RESOLVED, That our Texas Medical Association work with the Texas Hospital Association, Texas Department of State Health Services (as the agent for CMS), and other entities as needed to development reasonable standards for compliance that encourage timely completion of medical records, promote excellence in patient care, and do not unduly burden physicians and hospital employees who make reasonable and conscientious efforts to comply with national standards for medical record completion.
TMA House of Delegates: TexMed 2007