Risk Management Tips for Today's Medica Practice Voume II
2 Risk Management Tips for Today s Medica Practice. Voume II
Risk Management Tips for Today's Medica Practice Voume II In the compex and busy word of heathcare deivery, physician practices may overook basic office procedures that promote patient safety and reduce exposure to iabiity. This handbook identifies potentia risks and provides recommendations to mitigate them. Each tip is designed to address a common issue in the office practice and provide practica guidance on how to empoy best practices. These easy-to-impement recommendations are a guide for physicians, other heathcare providers, and staff. The impementation of these recommendations may assist in preventing adverse outcomes, improving patient care, and minimizing iabiity exposure in the office practice. Tip #11: Using Chaperones During Physica Examinations Tip #12: Promoting Communication Between Referring and Consuting Physicians Tip #13: Handing Patients' Compaints Propery Tip #14: Managing Drug Seeking Patients Tip #15: Communicating and Foowing-Up Critica Test Resuts Tip #16: Promoting Adherence to a Medication Regimen Tip #17: Communicating with Low Heath Literacy Patients Tip #18: Discontinuing the PhysicianÐPatient Reationship Propery Tip #19: Treating Patients with Whom You Have a Cose Reationship Tip #20: Reducing the Risk of the ªCopy and Pasteº Function in Eectronic Heath Records Risk Management Tips for Today s Medica Practice. Voume II 3
Tip #11: Using Chaperones During Physica Examinations The Risk: Providers must recognize that, at any time, a patient may make a compaint to the Office of Professiona Medica Conduct aeging that he or she was the victim of a physician's sexua misconduct. Having a chaperone present during intimate physica examinations may be beneficia to both the physician and the patient. First, it may provide reassurance to patients, demonstrating both respect for their concerns and an understanding of their vunerabiity. Second, the use of chaperones can provide ega protection for the physician in the event of a misunderstanding or fase accusation of sexua misconduct on the part of the patient. 1. A provider shoud aways use a chaperone when performing breast or pevic examinations. 2. Consideration aso shoud be given to the use of a chaperone for: recta and/or testicuar examinations; unusua situations where the physician is concerned that the patient, spouse, or famiy member may seem uncomfortabe or apprehensive; when a parent or spouse demands to be present; and when a patient acts seductivey or otherwise inappropriatey. 3. The presence of a chaperone must aways be documented in the patient's medica record. The provider can simpy document ªchaperone in room for the entire examº and the chaperone's initias. Adding the name and tite of the staff member who chaperoned the exam aows you to verify their presence at a ater date, shoud the need arise. 4. A tempate indicating the use of a chaperone is avaiabe from Fager Amser Keer & Schoppmann, LLP from which either a stamp for a paper record or a data fied for an eectronic heath record (EHR) can be used in your office. 5. A chaperone shoud be provided even if the provider is the same gender as the patient. 6. Chaperones shoud be educated about patient privacy and confidentiaity issues. 7. Uness specificay requested by the patient, famiy members shoud not be used as chaperones. 8. Respect for the patient's privacy can be further maintained by speaking to the patient privatey before and/or after the examination. 4 Risk Management Tips for Today s Medica Practice. Voume II
Tip #12: Promoting Communication Between Referring and Consuting Physicians The Risk: Lack of communication between providers may resut in poor coordination of care. This may incude a deay in diagnosis or treatment, the faiure to order diagnostic testing or act upon abnorma test resuts, or the faiure to prescribe appropriate medications. Ceary defining the roes and responsibiities of the referring and consuting physicians wi promote safe and effective patient care. 1. A tracking system shoud be in pace to determine if the patient obtained the recommended consutation. 2. Referring physicians shoud deveop a process for determining whether a report has been received from the consuting physician. 3. A consutation reports must be reviewed by the referring physician prior to being paced in, or scanned into, the patient's medica record. Paper copies shoud be initiaed and dated. 4. If a patient has been non-compiant in obtaining the recommended consutation, foow-up is necessary. Document a attempts to contact the patient and any discussions with the patient, incuding reinforcement of the necessity and reason for the consutation. 5. If a report is not received in a timey manner, contact the consutant to determine if the patient has been seen and whether a report has been generated. 6. Consutants shoud routiney send reports to referring physicians in a timey manner. These reports shoud incude the: findings; recommendations incuding interventions; and deineation of provider responsibiity for treatment and foow-up of test resuts. 7. The consutant shoud contact the referring physician when a patient fais to keep an appointment. The medica record shoud refect the missed appointment, as we as notification of the referring physician. 8. A teephone conversations between referring and consuting physicians shoud be documented. Timey communication must occur when an urgent or emergent cinica finding is identified. Risk Management Tips for Today s Medica Practice. Voume II 5
Tip #13: Handing Patients Compaints Propery The Risk: Patient satisfaction is an integra part of providing heathcare, regardess of the cinica setting. Dissatisfaction with medica care may be a harbinger of medica mapractice itigation. When you receive a compaint about care, how you hande the situation may directy impact the potentia for any future itigation. A physician office practices shoud have a poicy or protoco in pace to address patient compaints. 1. One individua shoud be identified and consistenty used as the primary person to address patient compaints. This is often the office manager. 2. A staff shoud know to whom compaints shoud be addressed, as we as what information constitutes a compaint that requires attention or intervention by that person. This shoud, at a minimum, incude: written or verba compaints regarding medica care; biing or payment issues that invove concerns about the cinica care; and etters of compaint from third party payors, IPRO, NYS Department of Heath, or other reguatory entities. We recommend that you retain persona counse for assistance in formuating written responses to such agencies. 3. Effective communication skis are essentia when addressing a patient compaint. Express concern for the patient's condition and webeing. Never be adversaria or defensive. Be an active istener and ask questions when appropriate. Avoid judgmenta comments about patients and their famiies, or negative remarks about staff, physicians, or other providers. Investigate compaints and foow up as indicated. 4. Conversations with patients shoud be documented in the medica record. It is appropriate to quote the patient when documenting their concerns. 5. Keep etters of response to compaints concise and simpe. A copy of the written response shoud be kept in the patient's medica record. 6. When compaints invove cinica issues or are compex, physicians or other providers shoud be invoved in addressing the situation. 7. Attorneys' requests for records may be an indication of a patient's unhappiness. The patient's medica record shoud be reviewed in conjunction with these requests in an effort to assess the potentia for medica mapractice itigation. 8. Consider seeking guidance when presented with unusua or difficut situations. MLMIC staff is avaiabe to assist insureds with handing compaints, formuating responses, and determining potentia exposure to caims of mapractice. 9. Never document any contact with MLMIC or your attorneys in the patient's medica record. 6 Risk Management Tips for Today s Medica Practice. Voume II
Tip #14: Managing Drug Seeking Patients The Risk: Heathcare professionas share in the responsibiity for minimizing prescription drug abuse and drug diversion. Physicians are tasked with differentiating patients in need of effective pain management from those who may be seeking drugs for inappropriate reasons. The foowing recommendations are intended to provide guidance for heathcare providers when confronted by drug seeking patients. 1. Perform a compete review of the patient's pertinent history, and conduct a thorough medica evauation. Address and document a objective signs and symptoms of pain. 2. Exercise concern when deaing with patients who are not interested in having a physica examination, are unwiing to authorize the reease of prior medica records, or have no interest in a diagnosis or a referra, saying they want the prescription immediatey. 3. Be cautious if a new patient has an unusua knowedge of controed substances, or requests a specific controed substance, and is unwiing to try any other medication. 4. Document a tria of non-narcotic medication and/or physica therapy before choosing to pace the patient on a controed substance. 5. If you are abe to identify the true source of the patient's pain, document that and any positive test resuts in the medica record. 6. New York State physicians must consut the I-Stop registry prior to prescribing any Schedue II, III or IV controed substances. To estabish a Heath Commerce System account to enabe you to do so, access the website at https://hcsteamwork1.heath.state.ny.us/pub/top.htm. 7. Document the patient's informed consent for treatment of chronic pain with controed substances. Have the patient sign a written pain management agreement (avaiabe from Fager Amser Keer & Schoppmann, LLP) when prescribing controed substances for chronic pain. 8. Specificay document drug treatment outcomes and the rationae for medication changes. 9. Assess whether further treatment for addiction or pain management is appropriate, and document this discussion with the patient. If necessary, refer the patient for consutation to a pain management cinic or to a rehabiitation faciity. 10. Carefuy monitor and protect Officia New York State Prescription pads if you use them. Uness an exemption is appicabe, prescriptions for controed substances are to be eectronicay dispensed. 11. When eectronicay issuing or writing a prescription for controed substances, write the quantity and the strength of drugs in both etters and numbers to prevent ateration. 12. Report patients who are reasonaby beieved to be habitua users or abusers of controed substances to the New York State Bureau of Controed Substances. This is required by New York State Pubic Heath Law 3372. 13. Contact the aw firm of Fager Amser Keer & Schoppmann, LLP to discuss how to address a patient who you beieve is seing/diverting narcotics, or atering, forging, or steaing prescription pads. Risk Management Tips for Today s Medica Practice. Voume II 7
8 Risk Management Tips for Today s Medica Practice. Voume II
Tip #15: Communicating and Foowing-Up Critica Test Resuts The Risk: The communication of test resuts is an important part of providing care and may invove various heathcare professionas. Test resuts may be overooked, ost, scanned into the wrong record, etc. Abnorma test resuts requiring foow-up present an additiona risk if they are not received, reviewed, or communicated to the patient. This may resut in missed or deayed diagnoses, patient injuries, and subsequent caims of mapractice. If a physician orders a test, he or she is responsibe for ensuring that the resuts have been received and reviewed. Physician practices shoud have poicies and procedures in pace for the management of test resuts. 1. A ordered tests must be documented in the patient's medica record. 2. A process shoud be in pace to confirm and document the receipt of test resuts. Many eectronic heath record systems aow practices to efficienty track pending aboratory/diagnostic studies. 3. A incoming aboratory reports and diagnostic tests must be reviewed and authenticated by the provider. 4. The provider must document communication of the test resuts to the patient. Any recommendations or interventions must aso be documented. 5. Providers shoud have a system in pace for the foow-up of pending aboratory/diagnostic test resuts for their patients who have been discharged from the hospita or emergency department. Receipt and review of these resuts shoud be documented in the patient's medica record. Communication of the resuts to the patient shoud aso be documented. 6. It is important for physicians to ceary estabish who is responsibe for foow-up when tests are ordered for a patient by another speciaist or consutant. 7. Patients shoud be advised of a test resuts, norma or abnorma. This communication shoud be documented in the medica record. Risk Management Tips for Today s Medica Practice. Voume II 9
Tip #16: Promoting Adherence to a Medication Regimen The Risk: Patient nonadherence to a prescribed medication regimen is a common probem that physicians in a speciaties encounter. Some factors that may infuence medication adherence incude the compexity of the regimen, the age of the patient, and the cost of medications. Patients and/or caregivers shoud be advised of the importance of taking medications exacty as directed. Educating patients regarding the use of medications shoud incude information about potentia drug interactions, side effects, and other reated probems that may warrant medica intervention. 1. Prescribing providers shoud educate patients about each medication, incuding its name, appearance, purpose, and effect. This education shoud incude any potentia side effects and/or interactions associated with the medication regimen. It shoud aso stress the importance of contacting a heathcare provider shoud any reactions, questions or concerns arise. 2. Query patients regarding any underying issues with medication seection in order to resove any concerns. 3. The importance of using ony one pharmacy to obtain a medications shoud be emphasized to patients or their representatives. 4. Patients shoud aso be advised to: keep an accurate ist of a medications incuding generic and brand names, over-the-counter medications, and herba suppements, which incudes dosages, dosing frequency, and the reasons for taking the medication; maintain a compete ist of medica providers and their contact information; post the name and teephone number of their oca pharmacy in a prominent ocation aong with the name and phone number of their physician; estabish a daiy routine when taking their medications; and bring a ist of a medications that they are taking to each and every appointment. 5. Make patients aware of the various medication adherence aids and devices avaiabe, such as dosing reminders, pi boxes, and refi reminder programs. 6. Provide usefu written information in pain anguage that ceary expains how patients can correcty manage their medications. 7. Consider utiizing the ªteach back methodº when expaining medications to patients. First teach the information, then ask patients to repeat it back in their own words. 8. Physicians shoud hep patients manage their medications, caution them to not share medications, and advise them to foow storage recommendations and dispose of od medications propery. 10 Risk Management Tips for Today s Medica Practice. Voume II
Tip #17: Communicating with Low Heath Literacy Patients The Risk: The ay pubic often has imited knowedge and understanding of medica terminoogy. A patient's abiity to understand medica information may be compounded by stress, age, iness, and anguage or cutura barriers. Effective communication with patients may improve compiance with treatment regimens, enhance the informed consent process, and increase safe medication use. Physician office practices can improve the patient experience, and reduce potentia iabiity exposure, by empoying the foowing recommendations. 1. Use ay terminoogy whenever possibe. Define technica terms with simpe anguage. Patient education materias shoud be written in pain anguage, avoiding the use of medica jargon. 2. Verba instructions may be reinforced with visua aids and printed materias that are easy to read and incude pictures, modes, and iustrations. Consider using nonprinted materias, such as videos and audio recordings, as indicated. 3. Offer to assist your patients when competing new patient information or any other practice documents. Provide this hep in a confidentia way, preferaby in an area that is private and conducive to this type of information exchange. Encourage your patients to contact you with any further questions. 4. The use of interpreters may be indicated for patients who are not fuent in the Engish anguage. 5. At the end of the encounter, use open ended questions rather than yes/no questions to further assess patient understanding. Instead of asking ªDo you have any questions?º try asking ªWhat questions do you have for me?º 6. Providers and staff shoud be famiiar with and utiize the principes of the ªteach back methodº when reviewing new medications or treatment pans with patients. First teach a concept, then ask patients to repeat back the information they just heard using their own words. 7. Patients and famiy members may be embarrassed by, or unaware of, their heathcare iteracy deficits. An empathetic approach to understanding patient heath iteracy wi enhance your physician-patient reationship. Risk Management Tips for Today s Medica Practice. Voume II 11
Tip #18: Discontinuing the PhysicianÐPatient Reationship Propery The Risk: Once the physician-patient reationship is estabished, physicians have a ega and ethica obigation to provide patients with care. However, there may be circumstances when it is no onger appropriate to continue the physician-patient reationship. A physician may choose to discharge a patient for a variety of reasons such as noncompiance with treatment, faiing to keep appointments, or inappropriate behavior. Propery discharging a patient from care can be a compex issue. In order to avoid aegations of abandonment, providers shoud consider estabishing a forma process for discharge. 1. The discharge of each patient must be determined by the physician on an individua basis and based on medica record documentation of patient noncompiance or disruption. We recommend that you contact Fager Amser Keer & Schoppmann, LLP for specific advice. 2. A forma patient discharge shoud be made in writing. You must give the patient at east 30 days from the date of the etter to ca you for an emergency in order to avoid charges of abandonment. This time period may be onger depending on the patient's condition and the avaiabiity of aternative care. 3. The three most common reasons why physicians discharge patients are: nonpayment; noncompiance with the physician's recommendations; and disruptions in the physician-patient reationship. 4. The discharge is to be effective the date of the etter. 5. Refer the patient to the oca county medica society, their heath insurer, or a hospita referra source to obtain the names of other physicians. 6. Provide the patient with prescriptions for an adequate suppy of medication or other treatment during the 30 day emergency period. 12 Risk Management Tips for Today s Medica Practice. Voume II 7. Use the USPS certificate of maiing procedure, not certified mai, to send the discharge etter so it can not be refused/uncaimed by the patient, and it can be forwarded if the patient has moved. 8. Discharge may not be an option in a situations. For exampe, discharge is not recommended if the patient: is in need of urgent or emergent or continuous care without a gap; is more than 24 weeks pregnant; or has a disabiity protected by state and federa discrimination aws. In these or simiar circumstances, the physician shoud discuss the patient's situation with counse before moving forward with a pan to discharge from care. 9. Become knowedgeabe about the requirements regarding any restrictions on discharge imposed by the third party payors with whom you participate. 10. Prompty send the patient's records to the patient's new physician upon receipt of a proper authorization. 11. Fag the office computer or other appointment system in use to avoid giving the patient a new appointment after discharge. 12. Document the probems that have ed to the discharge in the patient's record. 13. Form etters and a memorandum on the discharge of patients are avaiabe from Fager Amser Keer & Schoppmann, LLP.
Tip #19: Treating Patients with Whom You Have a Cose Reationship The Risk: Physicians are often asked by cose friends, reatives, or coeagues for medica advice, treatment, or prescriptions both inside and outside of the office. At times, these individuas may be seen by you as a courtesy and/or at no charge. Athough the American Medica Association advises physicians not to treat immediate famiy members except in cases of emergency or when no one ese is avaiabe, this practice continues to occur. Over the years, we have seen a number of awsuits fied against physicians by cose friends, coeagues, and even their own famiy members because of care provided by our insureds. The defense of these suits is frequenty hampered by the fact that there are often sparse or entirey non-existent medica records for the patient. The faiure to maintain a medica record for every patient is defined as professiona medica misconduct by Education Law 6530(32). Providing care under these circumstances may pose unique risks. Here are some recommendations about how to hande these situations. 1. Aways create a medica record for friends, reatives, and coeagues for whom you provide care of any kind. 2. A patient encounters must be documented in the medica record, incuding those that occur outside the medica office. 3. Take a compete medica history when seeing friends, reatives, or coeagues as patients. If indicated, this shoud incude issues that may be uncomfortabe to discuss, such as the use of psychotropic medications or sexua history. 4. A thorough medication history shoud be obtained from the patient to avoid potentia drug interactions. Identify any contraindications when prescribing medication. 5. Perform a thorough physica examination. Sensitive portions of a physica examination shoud be deferred when pertinent to the patient's compaints. These may incude breast, pevic, or recta examinations. A chaperone shoud be used for those portions of the examination. 6. Do not write prescriptions, especiay for controed substances, for individuas with whom you do not have an estabished professiona reationship. Aways document the reasons for prescribing medications aong with the dose. If narcotics are prescribed, consut the Prescription Monitoring Program (I-STOP) registry and document that in the medica record. 7. If a surgica procedure is to be performed: a signed informed consent form must be obtained and paced in the medica record; and the medica record must contain documentation that the informed consent conversation with the patient has occurred and that the patient consented to the procedure. Risk Management Tips for Today s Medica Practice. Voume II 13
Tip #20: Reducing the Risk of the ªCopy and Pasteº Function in Eectronic Heath Records The Risk: The ªcopy and pasteº function of eectronic heath record systems (EHRs) aows users to easiy dupicate information such as text, images, and other data within or between documents. Whie this function offers convenience and efficiency to heathcare providers, it aso poses unique iabiity risks when the information copied and pasted is either inaccurate or outdated. Further, using this feature may resut in redundancy within the new entry and create difficuty in identifying current information. 1. Deveop a comprehensive poicy and procedure for the appropriate use of the copy and paste function. The poicy shoud incude a process to monitor and audit both the staffs' and providers' use of this function. 2. Educate a EHR users about: the importance of verifying that the copied and pasted information is correct and accuratey describes the patient's current condition; the risks to patient safety in the inappropriate use of this function; and the importance of adhering to a reguatory, ega, and compiance guideines. 3. Determine what portions of the record shoud be copied and pasted. At a minimum, the heathcare provider's signature(s) shoud not be copied and pasted. 4. Confirm that the source of information which has been copied and pasted can be readiy identified and is avaiabe for review in the future. 5. Confirm that the history of the present iness is based upon the patient's description during that visit. 6. Use the medica, socia, or famiy history from a previous note ony after it has been reviewed with the patient to confirm it is reevant to the current appointment. 7. Verify that the diagnoses in your assessment are ony those addressed at that visit. Athough some EHRs aow the copying of a diagnoses in the probem ist, some may either have aready been resoved or they are not the reason for this particuar encounter. 8. Contact your EHR vendor as necessary to hep you and your staff compy with estabished poicies. This may incude the vendor making modifications which disabe the copy and paste function in designated fieds, and assisting in performing audits of the use of the copy and paste function by staff and providers. 14 Risk Management Tips for Today s Medica Practice. Voume II
Risk Management Tips for Today s Medica Practice. Voume II 15
For additiona Tips and risk management resources pease visit MLMIC.com The information contained in this brochure is prepared soey for genera informationa purposes and is not intended and shoud not be interpreted as ega advice or a ega opinion of any nature whatsoever. Pease consut an attorney for advice regarding your situation. New York City 2 Park Avenue New York, New York 10016 (212) 576-9800 (800) 275-6564 Syracuse 2 Cinton Square Syracuse, New York 13202 (315) 428-1188 (800) 356-4056 Latham 8 British American Bouevard Latham, New York 12110 (518) 786-2700 (800) 635-0666 Buffao 300 Internationa Drive, Suite 100 Wiiamsvie, New York 14221 (716) 648-5923 Long Isand 90 Merrick Avenue East Meadow, New York 11554 (516) 794-7200 (877) 777-3580