Q: Is there a rule that says a provider must complete a patients’ chart by a specific time? We have a provider does not complete the medical record in a timely manner. 

A: According to CURI, there are no specific rules about the timing of medical chart completion. However, Medicare providers must follow rules and timing. There must also be a signature. The rule states that providers complete the documentation “during or as soon as practical.” No billing can occur if a service is not recorded or signed off by the provider.  Completion  should take “no more than a couple of days.” Please visit the Centers for Medicare & Medicare Services (CMS) for more information.

For other patients, a provider should complete a patient’s record as soon as possible after each service or visit. This should be done within a 24-hour period. We recommend a maximum time of three workdays or 72 hours. Your practice should set a guideline that is reasonable for all providers, and then monitor compliance to this guideline.

In addition, under the 21^st CURES Act, an unreasonable delay in a patient/caretaker’s ability to get a copy of their medical notes could be considered information blocking.

Q: This is a two part question:

Part 1—A caretaker of one of our patients added other vaccinations on Form 3231 after we signed the form, and then gave the signed form to the school.

Part 2—We then received a request from this same caregiver to put a note in the child’s medical chart that states the child cannot get immunizations because of severe allergic reactions. We have never seen any such allergic reactions. The caretaker never reported a reaction before. We would like to remove (dismiss) this patient from our caseload.

A: If a parent  or legal guardian makes false statements about a child’s health status or falsifies a document, the patient can be removed from your caseload. However, that child cannot not be in a phase of active treatment at the time. You are not required to tell the caretaker why the child has been dismissed and it’s probably best not to do so. Please click here to view a sample letter. 

You can also decline to write a letter stating the child cannot get immunizations because you have not seen any reactions, nor have any reactions been reported to you. However, if the parent is now reporting these severe reactions, you should report them as being noted by the parent. Include that information in the medical record. This documentation should include:

• The common and brand-named drug or vaccine that may have caused the reaction;
• Include the strength and preparation of the item;
• A description of the reaction;
• Date and time of the reaction;
• How many times were the drug or vaccine given?
• How many days passed before the reaction appeared?
• How was the drug given(capsule, injection, etc.)? and

Which drug, drug classes (i.e., sulpha drugs)  and vaccines to avoid in the futur

How do we dismiss a patient? (July 2024)

How to respond to patient's complaints and demands?

Q: Can I discharge patients for refusal to vaccinate?

A: Refer to the guidance from the American Academy of Pediatrics that states:

• Some practices choose to terminate the physician-patient relationship when parents refuse vaccination. This is an individual decision; however, if a termination policy is implemented for such patients, it must be evenly enforced.
• The American Academy of Pediatrics advises that dismissing patients from a practice is not a decision to be taken lightly but is an option in circumstances in which all other recommended avenues have been exhausted.

Curi recommends that practices adopt a vaccine policy that is well-publicized in advance of establishing a patient-provider relationship and enforce the policy consistently. Providers should not terminate patients who are in an active phase of treatment.

Georgia Composite Medical Board Guidance

When considering termination of care, we advise following the guidance from the Georgia Composite Medical Board which states:

• “Yes, a physician generally has the right to terminate the doctor-patient relationship. In most cases, the physician may terminate a doctor- patient relationship upon giving the patient adequate written notice, preferably through certified mail. Physicians should give the patient adequate notice and a reasonable amount of time to find another health care provider. "Adequate notice" and "adequate written notice" are not legal terms and will depend on the circumstances. Generally speaking, 30 days is considered "adequate notice."

References:

American Academy of Pediatrics. (2013, May). Reaffirmation: Responding to Parents Who Refuse Immunization for Their Children. Doi: https://doi.org/10,1542/peds.2013-0430

Curi’s Risk Management Resource Document, Georgia Handbook: Patient Termination

Source: Curi

 Q: What is the proper procedure for vaccine errors? 

A: Curi recommends the following: 

• Develop a policy of responding to vaccine errors. 
• Contact the vaccine’s manufacturer to obtain recommendations. 
• Contact the state’s program manager. 
• Email CDC’s immunization experts: nipinfo@cdc.gov. Call the vaccine manufacturer. 
• Report the incident to Curi if there is patient harm or threats of litigation. 
• Provide regular training to staff on vaccine administration safety. 
• Verify staff competency in vaccine administration 
• Reference Curi’s Guidance on Disclosure of Adverse Events. 

Reporting Vaccine Errors 

CDC recommends that healthcare professionals report vaccine errors to the Vaccine Adverse Events Reporting System (VAERS). If an adverse event occurs following a vaccine administration, a report should definitely be sent to VAERS. Adverse events should be reported to VAERS regardless of whether a healthcare professional thinks it is related to the vaccine or not, as long as the event follows administering a dose of vaccine. 

Educational Resources for Vaccine Administration 

ACIP’s General Best Practice Guidelines for Immunization — This website covers a broad range of immunization topics, including detailed information about recommended vaccine administration practices, and is updated regularly. 

CDC’s e-Learn: Vaccine Administration – This training addresses knowledge gaps in proper vaccine administration. It highlights common mistakes and is designed to train providers to avoid administration errors by applying the “Rights of Medication Administration” to each encounter when vaccines are administered. www2.cdc.gov/vaccines/ed/vaxadmin/va/ce.asp 

Source: Curi

 Q: What are the recommendations and requirements for chaperoned exams for pediatric patients? 

A: Providers should follow Georgia’s Rule 360-3-.02 (12). There has been an update to Georgia’s chaperone policy. The new language is as follows: 

• Conducting a physical examination of the breast and/or genitalia without a chaperone present, unless the patient or the patient's parent or guardian specifically requests that a chaperone not be present for this portion of the clinical encounter which shall be documented in the patient's medical record.
• Physicians, at their discretion, may refuse to conduct an examination of the breast and/or genitalia without a chaperone present.
• In the previous version of the Rule, a chaperone was required only for patients of the opposite sex. ** Note that there are no age restrictions on this guidance.
• The physician should have a policy that patients are free to make a request for a chaperone. This policy should be communicated to patients, either by means of a well-displayed notice or preferably through a conversation initiated by the intake nurse or the physician. 
• The request by a patient to have a chaperone should be honored. It is recommended that an authorized health professional should serve as a chaperone whenever possible. In their practices, physicians should establish clear expectations about respecting patient privacy and confidentiality to which chaperones must adhere. 
• If a chaperone is to be provided, a separate opportunity for private conversation between the patient and the physician should be allowed. 

Institutions should have policies and training in place to provide chaperones for sensitive examinations, investigate, manage, and report complaints, and educate staff and volunteers about appropriate provider-patient boundaries. 

American Academy of Pediatrics 

Use of Chaperones During the Physical Examination of the Pediatric Patient 

1. Communication in advance regarding the components of the physical examination is of critical importance. Effective communication will help ensure that there is no misunderstanding about the reasons for and conduct of the examination. 
2. If the patient is an adolescent or young adult and the examination requires inspection or palpation of anorectal or genital areas and/or the female breast, a chaperone is recommended. However, the use of a chaperone should be a shared decision between the patient and physician. 
3. If a medical chaperone is indicated and the patient refuses, the patient or parent should be given alternatives, including seeking care elsewhere. 
4. Pediatricians should develop a policy about the use of chaperones in the office or clinic setting and document in the medical record if they are unable to adhere to the policy or state medical board regulations. 

Currently, the American Medical Association’s Code of Ethics, Use of Chaperones says any authorized member of the health care team can serve as a medical chaperone as long as there are clear expectations to uphold professional standards of privacy and confidentiality. 

Minor access to prep (pre-exposure prophylaxis) 

Georgia does not have any specific laws or statutes indicating the use of PrEP (HIV prevention) for adolescents. 

Mandatory Reporting Requirements 

Physicians have a duty to report suspected abuse of children, disabled adults, and the elderly to their local Department of Family and Children’s Services. The department then may assign a law enforcement officer to investigate the complaint. If an officer acting as an agent for the DFCS requests information related to child or disabled adult abuse, you should provide the information requested; the patient’s or guardian’s consent is not necessary for you to do so. However, the information given should be limited to the minimum amount necessary to fulfill the request. 

Source: Curi

 Q: Should a provider drug test patient at the parent’s request? 

A: Refer to the following guidance documents: 

AMA Journal of Ethics 

An adolescent with impaired mental status or one who has been involved in trauma, violence, or overdose should be tested for drug use. Testing can be a useful tool to monitor drug use in adolescents during drug treatment or maintenance programs. 

In clinical practice, physicians may encounter parents who suspect drug use and request a urine drug test with or without their adolescent's consent. 

When this occurs, the clinician should obtain more information about the parents' concerns, and they should be informed that a positive urine test does not give information about the drug use pattern, or presence of abuse or dependence. 

Similarly, a negative test does not indicate that the patient has not used drugs. 

The minor should be questioned alone, ideally with the clinician sharing information about the parent's concerns. Minors often consent to drug testing. For minors who refuse testing, it is rarely, if ever, appropriate to test, except in the emergency situations mentioned above. 

Whenever the minor agrees to testing, the physician must first develop a plan for disclosure of test results to both parents and adolescent before ordering the test. 

The American Academy of Pediatrics advises that testing can be an invasive breach of trust that may damage the relationship between parent and child.

If not done correctly, you may be viewed as a police officer rather than a parent, which does little to promote a healthy, trusting relationship. Even when state law allows parents to have a drug test performed on their adolescent child without consent of the adolescent, the American Academy of Pediatrics (AAP) cautions against involuntarily drug testing adolescents except in particular emergency situations. 

Risk Management Recommendations 

• Know the minor consent laws about substance abuse diagnosis and treatment in the state in which you practice. 
• Obtain a detailed description of the parents’ concerns prompting the drug test request. 
• Advise parents that a single positive drug test does not indicate substance abuse, and a negative test does not prove its absence. 
• Discuss parental concerns with the patient without the parents present. 
• When appropriate, obtain patient assent and permission to conduct the drug test and to share the results of the test before ordering the test. 
• Consider referring the minor to an addiction or mental health specialist if you suspect substance 

Source: Curi

Q: What is Reportable to DFCS? 

A: DFCS’s main concern is the primary caretaker’s ability to nurture and protect their children. All reports require the alleged maltreater to be a caretaker responsible for the child EXCEPT for child sexual abuse/exploitation or labor trafficking. In those cases, it doesn’t matter who is exploiting the child, it should be reported to DFCS. 

Reports that do not include allegations or suspicions of the criteria below, are likely to be screened out:

• Child physical abuse- Any non-accidental physical injury or death inflicted upon a child by a parent or caretaker. Physical forms of discipline may be used as long as there is no physical injury to the child. GA Code § 19-15-1 (2022)
• Child neglect- The failure to provide proper parental care, subsistence, education required by law, or other care needed for a child’s physical, mental, or emotional health; the failure to provide a child with adequate supervision; or the abandonment of a child by his or her parent, guardian, or legal custodian. (GA Code § 15-11-2 (48) (2022)
• Child sexual abuse and exploitation- Employing, using, persuading, enticing, or coercing any child to engage in any act which involves: sexual intercourse (genital, oral, annual), bestiality, masturbation, exhibition of the genitals in pubic, beating or torture by or upon a person who is nude, condition of being bound or physically restrained on the part of a person who is nude, physical contact for sexual stimulation or gratification, defecation or urination for the purpose of sexual stimulation, penetration of the vagina or rectum by any object (except as part of a recognized medical procedure), sex trafficking/sexual servitude exploitation (GA Code § 19-15-1(11) (2022)). Exploitation also includes sexually explicit conduct for the purpose of producing visual or print medium (film, photograph, negative, slide, magazine, or other visual medium). Code Section 16-12-100
• Sex Trafficking- Commercial Sexual Exploitation of Children (CSEC) refers to the sexual abuse or exploitation of a child for the financial benefit of any person or in exchange for anything of value given or received by any person.
• Sexual Servitude- Any sexually explicit conduct or performance of a child for which anything of value is directly or indirectly given, promised to or received by, any individual.
• Child labor trafficking- Work or service of economic or financial value which is performed or provided by another individual and is induced or obtained by coercion or deception.
• Child emotional abuse- Any act of a caregiver that causes observable impairment in a child’s ability to function within a normal range of actions and behavior or that create a risk of impairment. Examples of emotional abuse are verbal threats or bizarre punishment designed to isolate or humiliate by a caretaker. Exposure to domestic violence that results in emotional distress to the child is also consider emotional abuse. Exposure can range from witnessing, hearing, or perceiving the aftermath of domestic violence.
• Prenatal Abuse- Exposure to chronic or severe use of alcohol or the unlawful use of any controlled substance, which results in: 
  • Symptoms of withdrawal in a newborn or newborn testing positive 
  • Medically diagnosed and harmful effects in a newborn’s physical appearance or functioning. (GA Code § 15-11-2(56))
• Imminent risk of serious harm to the child’s physical, mental, or emotional health. 

How to Report 

A report must be made within 24 hours by phone or electronically. DFCS’ centralized intake is available 24/7 by calling: 1-855-GACHILD (1-855-422-4453) OR reporting online (requires online training prior to report):

• If the child is in immediate danger, report to law enforcement (911). 
• Comply with any internal workplace protocols. 
• For child resources and support, Call 1-800-CHILDREN (1-800-244-5373) to speak with a resource navigator or search the online resource map, FindHelpGA.org. 

When in doubt, make a report. If it is not reportable, it can be screened out by DFACs 

Source: Curi

 Q: We had request to release medical records to a 3rd party. We have a policy to release records to a medical provider or to an individual only. Are we required to release information to a third party? 

A: Yes. If requested by an individual, a covered entity must transmit an individual's PHI directly to another person or entity designated by the individual. The individual's request must be in writing, signed by the individual, and clearly identify the designated person or entity and where to send the PHI. See 45 CFR 164.524(c)(3)(ii). A covered entity may accept an electronic copy of a signed request (e.g., PDF or scanned image), an electronically executed request (e.g., via a secure web portal) that includes an electronic signature, or a faxed or mailed copy of a signed request. The records should be released within 30 days of the date of the request. 

Individuals’ Right under HIPAA to Access their Health Information 45 CFR § 164.524 

Source: Curi