The Health Insurance Organisation (HIO) fined two specialist doctors in June after finding incomplete clinical notes and insufficient documentation of their medical activity.
One of the two doctors, an orthopaedic specialist, not only failed to properly record the procedures he performed, but wrote a single word in the relevant field just to let the system move on to the next step.
The HIO imposed the larger fine, an orthopaedic doctor’s €1,000 penalty, on June 18. It imposed a €500 fine on a nephrology doctor on June 11.
In the orthopaedic doctor’s case, the HIO found the clinical notes field had been incompletely filled in for visits logged in the IT system.
As stated in the HIO’s related notice, this incomplete record-keeping meant the medical procedures carried out, and the necessity of the activities required, were not adequately justified or documented.
The HIO’s findings also covered referrals and prescriptions issued during those same visits.
The HIO noted that in a large number of cases, the clinical notes consisted of just one word. It also found that in most visits where referrals were issued, the corresponding referral notes field was similarly incomplete. This finding carried the same €1,000 fine noted above.
Properly completing clinical notes is considered essential, not only for HIO oversight purposes, but mainly to keep other GHS doctors treating the same patient informed. Failing to complete them correctly disrupts the flow of information between the doctors treating the same patient, with consequences for their proper care.
The second fine concerns a nephrology specialist and relates to insufficient documentation of a specific activity.
According to the HIO, the files uploaded to the system did not document that the required activity had actually been carried out.
Specifically, the HIO found that the attached file did not correspond to the declared activity and did not meet the minimum upload requirements.
The file did not include the test results as printed by the arterial blood gas analyser. This violation carried a €500 administrative fine.
