Compliance Essentials: Documentation

Documentation is one of the essential cornerstones of any effective compliance program.

Henry was understandably nervous on the day his office was being audited by the Office for Civil Rights (OCR). While still feeling some butterflies, he was confident that his compliance efforts will pass the HIPAA audit. Henry was then asked a series of questions:

Auditor - Does your office have establish policies and procedures?

Henry - Yes we do!

Auditor - Show them to me.

Henry - Here is a copy of our employee handbook.

Auditor - This does not contain the necessary written information.

Henry - I thought it was enough . . .

Auditor - Does your office train your employees continuously?

Henry - Yes we do!

Auditor - Show me the training documentation.

Henry - Our employees are trained on compliance every year at our annual "compliance and pizza" meeting.

Auditor - That is not what I asked for.

Henry - I thought it was enough . . .

Auditor - Show me your breach disclosure log.

Henry - Our breach disclosure log . . .

Auditor - Do you not have one?

Henry - I'm not even sure what that log is.

At this point in the audit, Henry's confidence has vanished and he is now thinking about the possibility of having to look for another job.

OCR has stated that it views compliance as an "ongoing journey". When you are on a journey, your attention is focused on what lies ahead. However, if you stop for a moment and look behind you, you will see past evidence of your journey in the form of footprints. If you turn around, you will be able to retrace your journey by following those footprints. If it was not for your footprints, you would not be able to retrace your journey back to where you started.

This same idea of retracing your footprints and being able to follow the history of your journey, applies to your "ongoing journey of compliance". However, rather then leaving footprints behind you, you leave a paper trail called, documentation. By keeping your documentation up-to-date, you have a history of your compliance activity and evidence of where you currently stand (policies and procedures).

There are numerous benefits to good documentation:

1. Paper Trail - This will be useful in demonstrating your compliance activity for an audit or possible protection against liability.
2. Compliance Story - It is not only about what you did and the final outcome, but rather what factors were a part of your decision making process and what lead you to make the final decision.
3. Hand-Me-Down - When an office changes Administrators or Compliance Officers, the newly appointed employee will be able to review previous documentation and have a better understanding of the organizations compliance history.
4. Employee "Misunderstandings" - Documentation of policies and procedures go a long way to eliminating the employee "misunderstandings" that tend to crop-up. If an employee says that they did not know the policy, you can refer to the written policy and their acknowledgement of it that they signed during their training.

During an audit by OCR, they are wanting to look at your "ongoing journey of compliance". If your documentation is done well and is up-to-date, then you won't have to shy away from their questions. Simply take their hand and guide them through the history of your "ongoing journey of compliance" by following your own footprints.

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