Risk Management including Documentation Stephen M. Perle, DC, MS Professor of Clinical Sciences University of Bridgeport College of Chiropractic No competing interests No association with providers of commercial products and/or devices discussed in this presentation and/or with any commercial supporters of these activities. 2 Risk starts when you start practice Some risks you know and choose others you might be unaware of Need to manage your risks Ignorance is no defense under the law 3 Stephen M. Perle, DC, MS 2012 1
THE Law You must know the rules Ignorance is no defense THE Law Statutes Rules and regulations Case law State AND Federal Legal risks Civil Administrative Criminal NB Fraud Criminal Civil AND Administrative 4 Regulations Administrative Get a local lawyer Local ordinances Join MCA ACA Medicare And pay attention On the web Board Check regularly things change 5 mn.gov/boards/chiropractic-examiners 6 Stephen M. Perle, DC, MS 2012 2
mn.gov/boards/chiropractic-examiners 7 Duty Malpractice/Negligence 4Ds Damages Directness Deviation 8 3% of patients actually injured pursue legal action Studdert et al. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38(3):250-60 9 Stephen M. Perle, DC, MS 2012 3
Studdert et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354(19):2024-33. 10 Studdert et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354(19):2024-33. 11 13% of total litigation costs due to claims without evidence of injury or error Studdert et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354(19):2024-33 12 Stephen M. Perle, DC, MS 2012 4
Or to put it another way 87% of malpractice payments are to people who were injured due to errors Studdert et al. Claims, errors, and compensation payments in medical malpractice litigation. N Engl J Med. 2006;354(19):2024-33. 13 97% who suffered negligent injury did not sue Studdert et al. Negligent care and malpractice claiming behavior in Utah and Colorado. Med Care. 2000;38(3):250-60 14 Standard Of Care Reasonably careful and prudent member of the same profession A moving target Standard of care is always changing! Can t know the future or can you? MCA - NCMIC Stephen M. Perle, DC, MS 2017 15 Stephen M. Perle, DC, MS 2012 5
Changing Standard Of Care Statute Case law Regulations Technology Training curricula Scope-widening tool practice what is taught in chiropractic colleges College s curricula changes standard of care thus changes Location MCA - NCMIC Stephen M. Perle, DC, MS 2017 16 Changing Standard Of Care Specialization Referral requirements held to standard of appropriate referral if not made Guidelines Mercy CCGPP Advertising Claims of superiority specializing in chronic and difficult cases Keep in mind advertisements last forever Res ipsa loquitur the thing speaks for itself MCA - NCMIC Stephen M. Perle, DC, MS 2017 17 Changing Standard Of Care Evidence Based Practice later MCA - NCMIC Stephen M. Perle, DC, MS 2017 18 Stephen M. Perle, DC, MS 2012 6
Deviation Of Standard Of Care Substance abuse by the doctor Substance abuse by the patient unreliable reporting of outcomes Failure to Obtain informed consent Advice of alternative treatments Diagnose and treat Fraudulent or excessive charges MCA - NCMIC Stephen M. Perle, DC, MS 2017 19 Deviation Of Standard Of Care Treatment outside of scope of practice Radiation exposure or burns Sexual misconduct Improper treatment Aggravation of pre-existing injury Poor quality radiographs or radiographic equipment MCA - NCMIC Stephen M. Perle, DC, MS 2017 20 Why Do Patients Sue? Top five reasons Dissatisfaction with care Believe they have been wronged Have a less than perfect result Rude caregivers Money 21 Stephen M. Perle, DC, MS 2012 7
General Risk Management Strategies Accurate Documentation Team Communication and Coordination Patient Rapport & good communication Informed Consent Evidence Based Practice Good moral compass 22 Lessons Learned From Locum Tenens PROBLEMS AND SOLUTIONS IN PATIENT COMMUNICATIONS 23 A COMMUNICATION PROBLEM 24 Stephen M. Perle, DC, MS 2012 8
Frequency Causes Risk Management Strategy Rude caregivers communication problems Establish professional rapport improve bedside manner Clear communication Money Clear financial policies 25 NBCE 2005 Job Analysis 4 3.5 3 2.5 2 1.5 1 0.5 0 3.7 Discuss treatment options 2.7 Provide written informed consent 2.3 Council about informed consent 26 Informed Consent Not a paper but a process Ensure decision is informed Patient has capacity to understand Patient does understand Patient has capacity to provide consent 27 Stephen M. Perle, DC, MS 2012 9
Elements Of Informed Consent Explain nature of procedures to be performed Disclose material risks inherent in procedure Disclose probability of occurrence of risks Disclose availability and nature of other treatment options Disclose material risks and probability inherent in those options Disclose risks associated with no treatment 28 Material Risk Mason v. Forgie Even if a certain risk is a mere possibility that ordinarily need not be disclosed, yet if its occurrence carries serious consequences, as for example paralysis or even death, it should be regarded as a material risk requirement disclosure. 29 Welcome to Connecticut 30 Stephen M. Perle, DC, MS 2012 10
31 http://www.ct.gov/dph/lib/dph/phho/chiropra ctors/declaratory_rulings/declaratory_ruling_reg arding_informed_consent_6_10_2010.pdf 32 Cassidy JD, et al. Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study. Spine. 2008;33(4 Suppl):S176-83. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. 33 Stephen M. Perle, DC, MS 2012 11
34 Informed consent is required of chiropractic physicians but not about stroke and manipulation Spinal manipulation on person who are having an acute stroke or cervical arterial dissection is not within the standard of care. 35 Minimal Standards For Documentation Stephen M. Perle, DC, MS 2012 12
The Dead Doctor Rule Documentation Communication between providers is fundamental to continuity of care. Only memory of the patient care. Indicates the quality of care the patient received. 38 Documentation Minimum Standards S.O.A.P. Legibility Patient identification Date and time the entry include the year Sign and page number Differential diagnosis Document follow-up care Correct by single line, initials, date, explanation void 39 Stephen M. Perle, DC, MS 2012 13
Documentation Don ts Do not use proprietary abbreviations or construct a glossary of your own symbols. Do not emotionally vent or assign blame Do not make an entry regarding risk management, occurrence report, etc. 40 Documentation Don ts Do not have every entry the same Do not fail to document phone conversations Do not leave blank spaces on the page 41 Documentation Don ts Never send Dictated but not read notes Do not sign for other people s actions (for associate or for employee) Do not make notes about care 24 hours later records must be contemporaneous 42 Stephen M. Perle, DC, MS 2012 14
Documentation Don ts Do not provide different level of documentation for different financial categories of patients Do not make patient sound sicker than they are Do not hide contraindications to a treatment Do not squeeze a note between two previous notes 43 Documentation Don ts Changing notes? A line through the error Write Void not error Sign & date Do not alter medical record Do not alter medical record Do not alter medical record Do not alter medical record Do not alter medical record Do not alter medical record 44 45 Stephen M. Perle, DC, MS 2012 15
46 Documentation Dos Document patient non-cooperation Document phone calls Document patient education offered or provided Outside test results should be noted Record normal findings as well as abnormal 47 Documentation Dos Document patient non-cooperation Document phone calls Document patient education offered or provided Outside test results should be noted Record normal findings as well as abnormal 48 Stephen M. Perle, DC, MS 2012 16
Records Must Be Written In Ink 49 Documentation Dos Record patient comments about concurrent care with other doctors Document attempts to receive information from other providers Document informed consent that obtained (ONLY if it was) Document when follow up should occur Always make sure records are legible records Illegible records = no records 50 SOAP S Patient presents with continued symptoms of intermittent right sided cervical pain with pain into right arm lateral arm and chest both ant and post. Additionally notes paresthesia in the 1 st 3 digits of right hand. Reports that pain has lessened and does not affect ADLs any more. VAS for pain in C 6.2cm, for Arm 4.2 cm. Or NPS C 6, for Arm 4. O C ROM WNL, Palpation of right scalene muscle produces twitch sign and exacerbation of patient s PP. P-A spring of C5/C6 is tender and exacerbates c spine symptoms. WEST 2g 1 st 3 digits of right hand, remainder of hand and contralateral hand 0.025g. The following ortho/neuro tests WNL: cervical compression, upper extremity mm tests A scalene myofascial trigger point with cervical joint dysfunction patient making expected progress P Tx: PIR to scalene and CMT r rot to C5/C6 well tolerated by patient who reports VAS for pain in C 4.8cm, for Arm 1.2 cm Commence standard cervical stabilization exercise program. Patient instructed in this program and given standard handout for daily exercise office visits biw 51 Stephen M. Perle, DC, MS 2012 17
47% of chiropractic claims were fraudulent Maintenance care Poor or no documentation Upcoding P - Pain A Alignment R - ROM T - Tone Optum 2015 2015 Stephen M. Perle, D.C., M.S. 52 Stephen M. Perle, DC, MS 2012 18