Health Information Management

News: Six cited for inadequate physician documentation

CDI Strategies, June 10, 2009

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Need to get your physicians onboard with your clinical documentation improvement program? Show them the list of sanctions revealed by the Texas Medical Board (TMB) in a June 3, press release. The TMB penalized six physicians for “inadequate medical records.”
 
Agreements ranged from requiring physicians take a medical recordkeeping course to charges of up to $2,000 in fines. To make matters worse, CBS-affiliated news station KFDM then posted the release on its Web site.
 
The release included the physicians’ names, license numbers, location, and description of the infraction which caused TMB concern. Each of the physicians entered into an agreement with board to the recommended remediation.
 
According to the release:
  • Gary Horndeski, MD, of Sugar Land, agreed to obtain 10 hours of continuing medical education in medical recordkeeping and pay an administrative penalty of $2,000 within 90 days. Horndeski allegedly failed to properly document patient assessment and physical examination, expectations for surgery, operative plan for initial surgery and for a revision. And for the revision, a reason for the change in the proposed procedure on the day of the surgery, for a liposuction patient.
  • Edward E. Louis, MD, of Dickinson, agreed to have a practice monitor for two years, based on alleged concerns over documentation of five patients’ charts that led to a temporary restriction on his practice in June, 2008.
  • Dee A. Roach, MD, of Colorado City, agreed to complete the medical recordkeeping course offered by the University of California San Diego Physician Assessment and Clinical Education (PACE) program, based on Roach’s failure to maintain adequate medical records on one patient.
  • Theodore D. Smith, DO, of Austin, agreed to obtain 10 hours of continuing medical education in medical recordkeeping; and, within one year, organize and present to his practice group a seminar discussing the treatment and diagnosis of depression and how to properly document treatment of depression. The action was based on Smith’s failure to properly document discussion of treatment options and whether there was suicidal ideation in a patient for whom he prescribed Prozac who committed suicide.
  • Jonathan E. Walker, MD, of Dallas, agreed to complete the PACE medical recordkeeping course and pay an administrative penalty of $1,000 within 90 days. The action was based on Walker’s failure to properly document his clinical testing and evaluation to show justification for his diagnostic conclusions and recommended treatment for two patients in his neurology practice.
  • McDonald H. Walker, MD, of Plano, agreed to complete the PACE medical recordkeeping course and pay an administrative penalty of $2,000 within 90 days. The action was based on Walker’s failure to adequately document the medical record of a three-year-old emergency room patient with regard to the wound, the prescribed antibiotics, his observations of the patient, and complete discharge instructions for a possible snakebite.



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