Public Health Law Map - Beta 5 - Medical and Public Health Law Site

eviewed completely by the supervising physician. The important items to document
are the subjective and objective findings that support the diagnosis under the
protocol, the decision-specific assessment, and the treatment and instructions
authorized under the protocol. (These recommendations must be modified by
appropriate Medicare evaluation and management [E&M] requirements.) Using the
example of strep throat, an adequate visit entry might read as follows:
S: sore throat ⋅ 3 days
O: TMs clear, chest clear, throat red, no adenopathy, rapid strep +
A: strep pharyngitis
P: Penicillin V K 250 mg q.i.d. ⋅ 10—dispensed Tylenol, rest, liquids, RTC 2
weeks for recheck, sooner if problems
This chart entry, made in a timely fashion and legibly, provides all the necessary
documentation for this encounter. It documents the trigger for the protocol and that
the protocol was followed in testing, treatment, and follow- up. The protocol itself
will provide the additional information to flesh out the chart note.
3. Quality Assurance
Quality assurance is as important in the private office as in large medical care
institutions. In hospitals or MCOs, there are many people who may observe the
medical practitioner. In small offices, if the physician is not checking on the people
he or she supervises, dangerous deficiencies may go unnoticed. The simplest form of
quality assurance for NPPs is to have the physician read and sign every chart. This
will allow correction of errors and ongoing education of the nurse or physician’s
assistant.
There should be a formal quality assurance program, usually a chart audit. Sample
charts should be reviewed for every provider and for a range of patient problems.
Each case should be evaluated to see if the protocols were followed and if the care
was documented properly. General considerations, such as whether the entries were
made at the time the care was rendered and whether they can be read by the other
providers, should be included in the audit. At intervals, the actual care rendered
should be checked. The chart entry may be perfect, yet bear no relationship to the
patient’s actual condition.
Every quality assurance program should have a system for correcting all identified
deficiencies. It must have provisions for changing questionable practices and for
immediately suspending anyone who may be dangerous to patients for any reason.
4. Drug Laws
Drug law violations account for most instances in which physicians lose their medical
licenses or go to jail. Drug law enforcement against physicians is often done by the
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