Ethical Case Study: Medical Record Audit

by | Jul 24, 2024 | ethics

Ethical Case Study:
Medical Record Audit
You are the Release of Information Supervisor in the HIM Department. In this role, you are responsible for assuring appropriate disclosures of health information. This includes responding to medical record audit requests for Government oversight agencies. You’ve received a medical record request from CMS, requesting the entire medical record for several Medicare patients. The purpose of this request is to validate the medical necessity for the care and services provided during the patient stay.
Following procedure, after obtaining the requested medical records, you send the records over to the utilization review team, who is primarily responsible for coordinating patient treatment and services to maximize patient care. This team also reviews all medical records before being sent to an auditor for medical necessity review. This process helps assure that all required components are included in the medical record to support the medical necessity of the encounter.
Upon the utilization team’s review, they find documentation in several progress notes inferring that the patient’s actual condition didn’t require the intensity of services that were provided. In other words, this documentation could invalidate the medical necessity of each visit and may result in rejection of payment for each encounter. If discovered by the auditor, the hospital will lose a lot of money. The utilization review manager has asked you to omit these progress notes from your submission to CMS so that the information is not discovered by the agency. She has assured you that “no one has to know about this and it will save the hospital a lot of trouble later on”.
What will you choose to do in this situation?

Answer the following questions for the scenario selected:
Scenario 1:
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.
Scenario 2:
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.
Scenario 3:
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.
Conclusion
1. Compare/contrast the three cases selected. In what ways are the ethical concerns similar? Different?
2. Interpret/discuss the ethical theory or theories that would best apply to the recommended courses of action for each scenario.
3. Develop steps for a leader to follow to assist with the ethical-decision making process.

Sample solution

Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell. 

In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.


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God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.

Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.

To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.

 

References

Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.

Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies, 4(8), 487.

Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.

Sample Answer

Sample Answer

 

Ethical Case Study: Medical Record Audit

Scenario 1

1. Ethical Concern

The ethical concern in this scenario is centered on the integrity of medical documentation and compliance with legal and ethical standards in healthcare. The request to omit progress notes that may invalidate the medical necessity of services provided raises significant issues related to honesty, transparency, and accountability. This action could lead to fraudulent reporting, jeopardizing not only the hospital’s financial standing but also the trust and safety of patients.

2. Handling the Scenario

In my role as the Release of Information Supervisor, I would first carefully consider the implications of omitting these progress notes. As a leader, it is vital to uphold ethical standards and ensure that patient care is prioritized over financial concerns. I would initiate a discussion with the utilization review manager to explain the potential consequences of their request, including legal ramifications, loss of accreditation, and damage to the organization’s reputation.

3. Recommended Courses of Action

– Refusal to Omit Notes: Clearly communicate that omitting essential documentation is unethical and could lead to serious repercussions.
– Document Everything: Ensure that all communications regarding this issue are documented for accountability.
– Escalate the Issue: If the utilization review manager insists on proceeding with their request, escalate the matter to higher management or the hospital’s ethics committee.
– Encourage Transparency: Advocate for a full and honest submission of all medical records to CMS, emphasizing that correcting any discrepancies will ultimately benefit patient care and organizational integrity.

Scenario 2

1. Ethical Concern

The ethical concern here revolves around compliance with healthcare regulations and the principle of truthfulness in medical documentation. By omitting progress notes that could negatively impact payment for services rendered, the hospital risks engaging in deceptive practices, which could constitute fraud.

2. Handling the Scenario

As a leader in this situation, I would prioritize ethical standards over financial gain. It is essential to emphasize the importance of adhering to legal requirements while also considering patient care implications. I would engage in a dialogue with relevant stakeholders to assess the situation comprehensively.

3. Recommended Courses of Action

– Conduct an Internal Review: Initiate an internal audit to review all patient cases with similar documentation issues.
– Develop a Plan for Improvement: Work with the utilization review team to create an action plan for correcting documentation practices moving forward.
– Educate Staff: Organize training sessions on proper documentation practices and the implications of omitting critical information.
– Report Issues: If necessary, report findings to CMS proactively, demonstrating the hospital’s commitment to transparency and accountability.

Scenario 3

1. Ethical Concern

The ethical concern here is about the potential impact of falsifying medical records on patient care and organizational integrity. The request to exclude certain notes compromises ethical principles such as beneficence (acting in the best interest of patients) and non-maleficence (avoiding harm).

2. Handling the Scenario

As a leader, it is crucial to address this concern immediately. I would ensure that all team members understand the importance of maintaining accurate records for both legal compliance and quality patient care.

3. Recommended Courses of Action

– Set Clear Policies: Establish clear policies regarding documentation that emphasize ethical practices and compliance with laws.
– Foster a Culture of Integrity: Encourage a workplace culture that values ethical behavior and transparency over financial outcomes.
– Support Whistleblowing: Create a safe environment where employees can report unethical practices without fear of retaliation.
– Reinforce Accountability: Hold all staff accountable for their actions regarding documentation and ensure that they understand the gravity of falsifying medical records.

Conclusion

1. Comparison of Ethical Concerns

The ethical concerns across all three scenarios center around integrity in medical documentation, adherence to legal regulations, and prioritizing patient care over financial gain. While each scenario addresses the same fundamental issues—truthfulness and accountability—the emphasis may vary; Scenario 1 focuses on immediate refusal of unethical requests, Scenario 2 highlights compliance through proactive measures, and Scenario 3 stresses fostering an ethic-driven workplace culture.

2. Ethical Theory Interpretation

The ethical theories applicable to these scenarios include:

– Deontological Ethics: This theory emphasizes duties and adherence to rules; in this case, maintaining accurate documentation is paramount.
– Consequentialism: This perspective evaluates actions based on their outcomes; omitting notes could lead to negative consequences for patients and the institution.
– Virtue Ethics: Encouraging virtues such as honesty, integrity, and accountability within the healthcare setting aligns with ethical decision-making.

3. Steps for Ethical Decision Making

1. Identify Ethical Dilemma: Recognize the ethical issue at hand.
2. Gather Information: Collect relevant facts, including organizational policies and applicable laws.
3. Consider Stakeholders: Evaluate how decisions will affect patients, staff, and the organization as a whole.
4. Explore Alternatives: Identify potential courses of action and their implications.
5. Consult Ethical Guidelines: Refer to professional codes of ethics and organizational policies.
6. Make an Informed Decision: Choose an action aligned with ethical principles.
7. Implement Decision: Execute the chosen course of action while ensuring communication with all involved parties.
8. Reflect on Outcomes: Assess the outcome of decisions made for future learning and improvement.

By adhering to these steps, leaders can navigate complex ethical dilemmas while fostering a culture rooted in integrity and accountability within their organizations.

 

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