Reference no: EM133170122

Quality Documentation

Billy is a medical record abstractor at a prestigious hospital, well known for its quality of care. In his role, he is responsible for reviewing the medical record and inputting data from the medical record into a quality measures database.  The quality measures database is then used to report specific quality measures as mandated for accreditation. As an abstractor, Billy must fully input data exactly as it is stated in the chart. The motto "If it wasn't documented, it wasn't done", applies to his job.  When inputting the data, Billy notices that the facility is about to fail one of the quality measures due to a lack of documentation. The quality measure indicates that all patients who are admitted with a stroke diagnosis must be given clot-prevention medication unless there is a contraindication noted in the chart. If the patient is not given the medication and a contraindication is NOT noted, then the chart fails the quality measure.  Billy searches the chart and finds no documentation, therefore, the chart fails the quality measure.  Upon review, he notices several charts with the same issue (No documentation to help support the decision of the care team.)  He makes a note to notify the Quality Committee so that improvements can be made to the documentation templates in the electronic health record.  Billy continues with his work and submits his abstracted data into the database.

John works in the quality department as a quality measure reviewer. His job is to double-check the submissions from the quality database and review all measures that fail.  John notices that several of Billy's abstractions come back as failures for "lack of documentation". Not wanting to fail the upcoming accreditation, John requests Billy to go back and change all of the abstracted data so that it passes the measure.  When Billy informs John that the quality measure specifically states that the information must be clearly documented, John says "It is my job to assure our organization is compliant with quality measures. In the big scheme of things, this is just a small task that will benefit our organization".

Billy, feeling conflicted between helping the organization and doing the right thing, takes the issue to you as his leader.

What should be done in this situation?

1. Identify whether there is an ethical concern, and if so, what the ethical concern is.
2. Determine how the scenario should be handled. For instance, if you were the leader in the selected situation, how would you manage the issue?
3. Recommend course(s) of action to be taken.