Documentation of Care and Other Challenges

Consequently, while each patient care circumstance is different, you may want to augment your documentation to reflect the impact of COVID-19.  In some, but not all, clinical settings, certain tests, procedures, or plans of care may need to be adjusted given COVID-19.

Additionally, you may find yourself having to collaborate with other healthcare professionals in ways that are different during the Pandemic than in more usual times.

Just as in usual and customary times, healthcare professionals are encouraged to use their clinical judgment in the environment in which they are currently treating their patients and document the rational for the care path that is chosen. To assist you during these challenging times, we have put together some suggestions regarding documentation and processes for your consideration as you navigate through the murky waters of the Pandemic.

One challenge is the potential for reduction in both the types of medical services available and the practice hours. The Pandemic has caused many providers and facilities to modify their practice hours, move from providing specialty services to emergency-only care, transition to telehealth, or close their physical practices for a short time. When a disruption occurs in the regular routine of a practice or patient, healthcare professionals have to find new ways to make sure important tasks are performed.  Alternatively, healthcare professionals may need to communicate to the patient why there is a delay regarding a particular test or a certain procedure. In such communications, the healthcare professional will be well served by explaining to the patient the reason for the delay and the impact of such delays.  Provider communication with patients and documentation thereof are key elements in mitigating the liability risk during the Pandemic.

The following scenarios may assist providers in addressing issues that arise regarding the monitoring, testing, and follow-up that occurs in this new, albeit temporary, COVID-19 environment of care.

1.  The patient is unable to receive laboratory, radiology, or specialty services.
Imagine you are a primary care provider who is having difficulty scheduling or referring patients for care given the lack of such services due to COVID-19. Or perhaps, you are a healthcare professional who has had to cancel or postpone certain testing or specialty services due to the Pandemic. Below are some options and tips you might consider:

• Consult with the service provider to determine what criteria are in place for the requested service. When appropriate, collaborate with the healthcare team involved in the patient’s care until the requested service can be provided.
• Communicate with the patient and document in the patient’s medical record the criteria used to determine why the requested testing or specialty service is canceled, not ordered, or postponed. Discuss and document the risks versus benefits of the delay. Discuss and document with the patient symptoms or changes that may occur and inform the patient when the patient should contact the provider immediately. Document other relevant discussions and the plan of care.
• Facilities, laboratory, radiology, and specialty service providers may find it helpful to have ready the criteria for canceled or postponed services to referring providers. When possible and applicable, they should take steps to collaborate with the referring provider as the medical team cares for the patient during the Pandemic. Consultations and collaborating medical care should be documented in the patient’s medical record.

2.  The patient missed clinic or telemedicine appointments, laboratory, or radiology exams.
Imagine the patient fails to show up for their scheduled appointment or ancillary exams, regardless of whether it is an in-person or telehealth visit. Depending on the circumstance, and when appropriate, the healthcare professional might consider some of the following options and tips:

• The healthcare professional or hospital or clinical staff are encouraged to contact the patient and document whether the patient was reached.
• If the patient is reached, note the reason the patient did not arrive as scheduled if you are able to obtain that information from the patient.
• There may be instances of anxiety on the part of the patient in leaving their home given the possible risk exposure during the Pandemic. If the patient indicates the patient does not want to proceed with an appointment, if possible, and as appropriate, offer alternatives to care and discuss the risk of not having future care. Discuss the risks versus benefits of those alternatives as well as the risks versus benefits of postponing laboratory or radiology exams, when appropriate. If relevant, document the steps taken to help reduce the patient’s anxiety during the provision of medical care.
• If there is an issue with a telehealth visit, such as a lack of understanding of how to use the technology, poor cellular service, or inadequate band width, work with the patient to resolve the issue and document the outcome. If your practice is not offering in-person visits, you may have to be creative on how you communicate with the patient to meet their medical needs. For instance, you could have a verbal-only landline telehealth visit. Or you could suggest the patient drive to an appropriate location where the cellular or internet service is strong enough to have an appointment in their vehicle. The location should also be somewhere they will be able to maintain personal privacy and dignity.

3.  Review and Communication of test results from laboratory, radiology, or specialty during COVID-19.
Clinics and hospitals may temporarily close practices or practice areas, modify practice hours, work with limited practice staff, or transition to telehealth visits during the Pandemic.  As a result, clinics and hospitals may find themselves having to adjust their normal processes for reviewing the test results and communicating the results to patients.   Options and tips for dealing with the situation include:

• As appropriate, work with the clinical and administrative teams to adjust the normal routine to accommodate environmental changes caused by the Pandemic.  Given the disruption caused by the Pandemic, clinics and hospitals may find it helpful to heighten their focus on managing test results.  By focusing on adherence to the process for reviewing and communicating test results, healthcare professional can militate against unnecessary delays in reviewing and communicating test results during these difficult and challenging times.
• If delays occur in the review or communication of a test, consider documenting the reason for the delay, e.g., COVID-19; discuss how the Pandemic added to or caused a delay.  Document the fact of review and communication to the patient.

4.  Results from laboratory, radiology or specialty service were not received.
Occasionally, a healthcare provider will order testing on a patient and not receive those results back from the laboratory, radiology, or specialty service. While there may be numerous reasons for this, the ordering healthcare providers can enhance their relationship with their patients with various proactive steps. Below are some examples of those steps.

• An ordering healthcare provider’s electronic health record (EHR) may have a module to alert the provider when a test result has not been returned in a specified time frame. If the provider has such an EHR, it may be beneficial to have it turned on and set to alarm in an appropriate period of time.
• If the provider does not have this EHR module in the EHR or does not use an EHR, the healthcare provider could consider some sort of tracking or calendaring system (a “tickler” system) to assist with tracking test results.
• If an expected result does not arrive or a patient calls about a result, the ordering healthcare provider can reach out to the service provider to understand why there have been a delay and communicate the explanation to the patient. Consider documenting when and how the service provider was contacted and the timing and communication to the patient regarding the outstanding test. If the service provider indicates the delay was due to modified COVID-19 procedures or other COVID-19-related reasons, document these explanations as well and reference the Pandemic. The ordering healthcare providers may find that they need to reach out several times before the test result is returned given the disruption of the Pandemic. Once the test results are received, the provider should communicate the result to the patient and discuss the plan of care going forward.

KAMMCO Risk Management Recommendations:
Below are some suggested guidelines regarding documentations that you might consider:

• Document in the patient medical record consultation and collaboration requests for patient services.
• Document criteria used in decision-making processes, rationales, and discussions with each patient regarding canceled, not ordered, or postponed testing or specialty services.
• Document the patient’s informed consent, including the discussion of the risks versus benefits to cancel, forgo, or postpone testing or specialty services in light of the COVID-19 pandemic.
• Document instructions to the patient of warning signs and symptoms of conditions they may experience as a result of canceled, postponed, or non-ordered testing or specialty services. Document the patient was told when they should call the provider if such warning signs or symptoms occur.
• Document patient “no-shows”, contact the patient regarding the missed visit, and work through the issues their non-arrival has posed. Document the discussion and outcome.
• Encourage the patient to contact the practice or provider if they have not received communication regarding their test results in a specific time period.
• Use a triggering mechanism to flag missing test results for the provider.
• Document when procedures implemented by testing sites or the practice because of COVID-19 have played a part in test results being delayed or missed.
• Document communication with the patient in the patient’s medical record.

For more information and resources on the COVID-19 crisis, please visit the COVID-19 Resources section of the KAMMCO Risk Management Tools and Resources page.

This document should not be interpreted as medical or legal advice. Because the facts pertaining to your situation may fluctuate, or the laws in your jurisdiction might vary, please contact your attorney if you have questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions​.