Part 1 of 2 .

By Patricia Ramos, AuD

How many times have you seen a patient in the office for a follow-up visit only to find that the information that you really need to serve the patient is not there?  This can happen when you are the only provider in a practice but, especially if there are multiple providers involved in the care of the patient.  Let’s be honest, when you work in a multispecialty, medical environment there are many variables that can lead to missing documentation, both diagnostic and rehabilitative components of documentation can be extensive based on the number of subspecialties that are provided within your practice. 

Let’s review two scenarios that you might discover in a chart audit.

Patient calls in and needs a tubing change or a possible receiver replacement. In reviewing the chart, you realize that you did not document the tubing size or the receiver strength.

• As a solo practitioner in a medical practice providing audiology care, we often get to know our patients very well and there is a lot of information often obtained from the patient in each visit.  This leads us to have the challenge of covering all needed areas with the patient, but also documenting it for further future reference. When I first started seeing patients clinically as a solo provider, and yes, of course I was younger, I could remember the patients by their names, their stories, their needs or patterns, (never changed a wax guard, would put the batteries in the HA’s without removing the paper).  It is not uncommon for us rely on our interactions and memories of patients concerns as opposed to assuring that we have a documentation plan that is consistent and also allows for us to document quickly and accurately.
• Because of the lack of documentation of tubing size or receiver strength, the only way to address the patient’s needs is to have them come back into the office before care can be initiated versus being able to assure the patient that we can address their problem in an office visit. A great example of this would be making sure one has proper wax guards or receivers in stock before the patient even arrives to the office.

A patient is seen with a complicated asymmetric hearing loss where a masking dilemma could occur. Upon review of the audiogram presented from previous testing, you are unable to assure that the thresholds depicted are accurate because there are no recorded effective masking levels recorded.

• As an audiologist, we must make sure that we are confident in the test results that they have led to an accurate initial diagnosis. Medical and surgical decisions surrounding a patient many times are solely based on the audiometric results. If previous testing performed does provide all needed information, the only option is to “retest”.
• If you proceed with making recommendations based on results that you did not obtain personally and you cannot with certainty know that the thresholds are valid due to lack of recorded masking levels, you could be sending a patient to surgery on improper results and surgery is not indicated.

As you can see from the simple scenarios given above, with only one piece of information missing in the documentation of each example, proper patient care was delayed because the missing information did not allow us to provide care with confidence, therefore requiring additional time on the patient and the provider.

Whether you are using some form of electronic health records program, handwritten notes, or dictating, the key to documentation is having a plan/outline that will allow you to document quickly but thoroughly without missing vital information.   One way to do that is to have appointment specific chart note templates that outline the components of each visit type so that as a provider you have all required components of the visit identified, i.e., diagnostics: case history questions listed and only need to  input the answers given by the patient;  Hearing Aid Fitting Note Template where all information needed for the devices and the fitting i.e. conformity examination performed, reviewed all components and their care/maintenance are also outlined.

Once you have established the components of the chart review process, the next most important step is to determine what to do with the information obtained.

1. Determine and prioritize the potential areas of improvement
2. Create a clinical documentation plan that is specific to the provider that you are reviewing
3. Commit to ongoing clinical chart review to document improvement, self- review and peer review

Documentation is key to patient care and being able to defend yourself in a chart audit, either from an insurance company or a medical malpractice claim.

Let’s start with the basics:

• Is there a medical order in the chart for diagnostic testing performed?  This is required in audiology for billing purposes, and you can only bill what is “ordered”.
• Is the patient’s name, medical record number (MRN) and date of service (DOS) included on every page of documentation for the patient?
• Is there documented medical necessity in the chart, i.e., reason for appointment? must always be medically based to be able to retain the monies paid upon audit.
• Do the services that were rendered match the patient complaint and documented history?
• Does the audiogram and other testing results have the information as required by your state?  Calibration date, Name of equipment and credentials of who is performing the testing to name a few.
• Do you have appropriate time stamped or written signatures of the provider that is billing for the services?
• Are physical exam findings documented, complete, accurate and appropriate for the patient reported symptoms and test ordered?
• Is all documentation accurate and legible?
• Is there clear documentation of the assessment, clinical impression or diagnosis for all testing performed, and plan of care for the patient?

Need a place to start? Look for the Chart Audit Form in May!

Things to know when you are a provider in a multispecialty practice.

As we know the risks associated with audiology are pretty low compared with physicians’ and surgeons’ risks.  Accordingly, the premiums for coverage are also very low and the coverage usually broad and comprehensive for the most part from the insurers that do offer this specialty coverage.  However, there still are important considerations in purchasing coverage that every audiologist working with a medical practice needs to take into account. 

The first and most important detail in the coverage arrangement for audiologists working with physicians, most commonly with otolaryngologists, is how the coverage is set up. 

In many practices, we see audiologists included in the malpractice insurance covering the physicians and the practice’s corporate entity.   Most standard physician’s malpractice insurance does not exclude audiologists so they are automatically included without any separate listings or paperwork.  This coverage is always on a “shared limits” basis that automatically extends the same liability limits that the doctor and corporate entity carry.  Sometimes the physicians are covered with their own set of limits and the corporation and employees are on a separate limit, but in both cases the audiologists are covered. 

That is all easy and clean. However, we find that many audiologists then go out and purchase additional individual coverage from a different insurer, often with much higher liability limits than the practice and doctors purchase since the audiology coverage is so cheap.  This independent coverage unfortunately creates two problems.  The first is that if or when a claim arises involving the audiologist almost always the doctor and corporate entity are also sued, with the audiologist now involving their insurance company claims defense team of lawyers and company claims representatives while the physician and practice will be defended by a whole separate defense team.  Predictably in most any arrangements like this with different defendants in the same lawsuit being defended by different insurers, finger-pointing and casting of blame to the other defendants becomes the plaintiff attorneys’ dream because of the divided defense.  The vastly better defense strategy is to have a unified defense handled by one insurer. 

The second problem with separate coverage from different insurers for the audiologists and doctors is that at least in Florida where most doctors carry relatively low liability limits, the audiologists are purchasing much higher limits than the doctors because the cost is so cheap.  Higher limits can lead to being a “deep pocket” in a multi-defendant lawsuit, and that can become a big issue when different insurance companies are defending the doctors and audiologists. 

Ultimately, it is recommended that audiologists and physicians practicing together purchase insurance, when possible, from the same insurance company.  

For additional information, find details here.

Over my career, there are a number of in real life lessons that I have learned. For those of you that have practiced for a few years, I’m sure you can relate. Those tips and lessons that you weren’t taught in school, that make up that underlying wisdom in which you bring to your work each day. As you get to know me, you will find that I share the good, the bad and the ugly, so that I don’t forget, and others can learn from my experiences.   So, with that said, let me tell you about an experience that not many audiologists have in their career, at least I hope they have not….

One of the things that I have always loved working in the medical audiology space is the ability to see difficult cases and work toward the best patient outcome in conjunction with the physician.  As many of you know, working closely with physicians allows for collaboration at all stages of the diagnosis and treatment plan, but also opens up the potential exposure to medical malpractice/negligence claims – at all stages of the patient’s diagnosis and treatment. What do I mean by this?  Well, this is where the story begins. 

A number of years ago working in the medical audiology role, I had the great misfortune of being named in a shotgun approach to a medical malpractice case involving, not one, but two of our physicians at the same time.  When I look back, this was one of those moments where my training intersected with real-life, professional experience.  Until that time, malpractice and negligence cases were just something I knew occurred in medicine, but not something I thought about often, or ever worried about happening to me.  It was a rude awakening to be named in a malpractice case, sit in arbitration off and on for almost 3 years and listen to the lawyers share their perspective about all my physicians and I had done, could had done, or in their opinion, done incorrectly. Additionally, what I realized, was that once the attorneys were involved, the “truth” about the actual case was not necessarily the center focus.  Our attorneys’ role was to prove the case had no merit, or at minimum, present evidence that would have the least impact to the medical malpractice provider. The question became: which approach would be most effective and least costly to manage the lawsuit?

There is a lot to this story, but the audiology part goes like this…

1. Female patient presents with mixed loss with multiple reconstructive surgeries from other physician practices. 
2. Testing confirms the loss and patient sent to surgeon to discuss surgery
3. Patient returns to audiology after declining surgery (she had 3 previously)
4. Discussed amplification benefits & medical contraindications to hearing aid use with open perforation
5. Patient chose to move forward with amplification
6. Behind the ear hearing aid with ventilated mold ordered
7. Patient fit and counseled on importance of intermittent use of device to allow for more effective ventilation of ear as well as need for continued medical and audiological follow up to monitor health of ear.
8. Patient did not hold to the medical or audiological recommendations
9. Returns to office approximately 2 years later for follow up visit
10. Audiological evaluation determined dead ear on previously amplified ear
11. Medical course of hearing loss led her to have meningitis.
12. Eventual loss of all hearing on that ear of which she was not seen by our physicians or myself
13. Patient asked for re-fitting of device to her father (it was a digital programmable device)
14. Hearing aid was refit to father and chart put for filing
15. Received “summons” of being served in the medical malpractice case for the patient
16. Attended multiple depositions/arbitrations over 2 + years
17. Decision was made by the malpractice company to settle in the case
18. Multiple attempts were made to try to have myself removed from the suit
19. At the last day prior to settling on the case and filing with the court, I WAS DROPPED FROM THE SUIT!

Unfortunately, everything we learn, we don’t learn in kindergarten. 

– some wise person

What were the lessons learned?

1. Not all malpractice or negligence cases are filed based on truth, many are filed based on money.
2. As a provider, even with the best intentions for your patient, it is still possible to be falsely accused.
3. It is the attorney’s job to tell a story – and that comes from the documentation or lack of documentation, and without documentation, that story can be quite colorful and flat out incorrect. In this instance, I was accused of destroying the medical record. This was due to the inability to produce the original hearing aid chart, which was finally located about a year and half into the case. It had been misfiled in another patient’s chart by our front office staff.
4. The stress of this type of experience does make you a more conscientious provider, but it is a hard way to learn those lessons.
5. Documentation is KEY – If it is not written, it did not happen.
6. How you are insured as an audiologist for medical liability is EXTREMELY important.

“Needless to say, I would never want any medical audiologist to endure the stress of being involved in a malpractice case, but what I learned is that the type of coverage you have when working in a medical practice needs to align with the physician and practice coverage.”

This is why I worked with a Medical Malpractice provider to develop a coverage that provides the best protection for the practice, physician and audiologist. Check it out here!

Watch for the MedAudPro Risk & Compliance Library coming in May!

About Patricia Ramos, AuD

Dr. Patricia Ramos is the Director of Audiology and Rehabilitative Services at ENT and Allergy Associates of Florida; she joined the practice in 1993. Currently, Patti oversees a team of 100+ comprised of audiologists & students, audiology assistants and audiology operations that cover 60 locations. Her department is involved in multiple FDA clinical trials & has been a leader in developing, training & utilizing audiology assistants for greater than 15 years. Dr. Ramos is an internationally recognized expert and speaker in the field of Audiology, ENT-Audiology collaboration and all aspects of hearing rehabilitation. She continues to be active as an adjunct professor, serves on multiple boards and is a key opinion leader for the hearing and audiology-related FDA trial Industry. She received her Doctorate in Audiology from the University of Florida.