Documenting non-compliance in health care records

Non-compliant patients: ©Syda Productions - stock.adobe.com

Imagine you have a patient with diabetes that you have treated with aggressive intervention and medical adjustments but presents with uncontrolled glucose readings and an elevated hemoglobin A1c.You suspect non-compliance but your patient reports compliance with medications, diet, and lifestyle despite contrarian evidence. Should you tell them that the story does not align and that they appear to be non-compliant? Will this hurt the clinical relationship, or will it help to provide motivational influence to do better?

The relationship between clinician and patient is paramount in health care-characterized by trust, respect, and collaboration. At the heart of this partnership lies effective communication, ensuring that patients are fully informed about their conditions, treatment options, and responsibilities. However, a dilemma arises when health care providers have to address or document possible discrepancies between patient reported behavior and evidence to the contrary. As clinicians navigate the complex landscape of patient care, value-based contracting, reimbursement, and clinician ratings, questions arise about the ethical and practical implications of documenting patient noncompliance in medical records, particularly using codes such as Z91.19 (patient's noncompliance with other medical treatment and regimen). Clinicians may worry this will hurt the relationship with patients or adversely affect care.

The use of ICD-10-CM code Z91.19, indicating "Patient's noncompliance with other medical treatment and regimen," can be a contentious issue within the health care community. While some argue that documenting noncompliance serves to accurately reflect patient behavior and improve continuity of care, others raise concerns about the potential consequences for patient-provider relationships and trust. On one hand, clinicians may propose this may help to influence behavior with acknowledging patient’s compliance and perhaps addressing the reasons why when confronted. However, others may suspect that a patient may find this be contentious or argumentative if a patient feels otherwise.

Primarily, it is crucial to acknowledge that documenting noncompliance is not a judgment of the patient's character or worth. Instead, it is a factual representation of the patient's behavior regarding adherence to medical treatment. By including such information in medical records, clinicians uphold their ethical obligation to provide comprehensive and accurate documentation. Factual documentation is essential for continuity of care and informed decision-making with our patients. Accurate documentation also helps to provide supporting evidence to the challenges of meeting population health metrics, as well as its potential fiscal impact and satisfaction ratings.

The discussion of non-compliance deserves to be had, but the effectiveness of such is all in the delivery of the conversation. Documenting noncompliance can serve as a catalyst for meaningful conversations between clinicians and patients. When clinicians openly address issues of non-adherence, they create an opportunity to explore the underlying reasons behind patient behavior, whether they stem from socioeconomic factors, cultural beliefs, psychological barriers, or other influences. Through compassionate and nonjudgmental dialogue, clinicians can collaboratively develop strategies to overcome obstacles and enhance treatment adherence, ultimately improving health outcomes.

However, the decision to document noncompliance should be approached with sensitivity and discretion. Clinicians must consider the potential impact on patient-provider relationships and trust. Patients may feel stigmatized or disempowered by the inclusion of noncompliance in their medical records, leading to strained relationships and reluctance to engage with healthcare providers in the future. Therefore, it is incumbent upon clinicians to exercise empathy and cultural competence when discussing noncompliance with patients. Rather than focusing solely on documentation, clinicians should prioritize patient-centered care, emphasizing shared decision-making, mutual respect, and individualized support. By adopting a collaborative approach, clinicians can foster trust and rapport with patients, facilitating a therapeutic alliance grounded in empathy and understanding.

A clinician’s determination of documenting non-compliance must weigh the overall impact of such. Will such documentation mitigate risks of perceived poor patient care, mitigate risks of pay-per-performance or will it overall benefit the patient care and improve patient outcomes? This is the fundamental question.

In conclusion, the ethical imperative of patient-centered care necessitates thoughtful consideration of the role of documentation in health care records. While documenting noncompliance using codes such as Z91.19 serves to ensure accuracy and continuity of care, clinicians must balance this with the preservation of patient-provider relationships and trust. By approaching the discussion of noncompliance with empathy, cultural sensitivity, and a commitment to patient-centered care, clinicians can navigate this complex terrain while upholding the highest standards of professionalism and ethical practice.

Dr. Jesse Bracamonte is a Mayo Family Medicine Physician in the Dept of Family Medicine, Mayo Clinic, Arizona. Dr. Mike Underhill is a Mayo Family Medicine Physician in the Dept of Family Medicine, Mayo Clinic, Arizona. Dr. Ashley Stillwell is a Mayo Family Medicine Physician and Psychiatrist, Mayo Clinic, Arizona.