The Top 10 Risk Management Issues
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[The guidelines suggested in this article are not rules, and they do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.]
What are the most frequent risks facing the medical office practice today? What strategies can minimize risks that might result in patient problems and professional liability claims? The following list identifies frequent risk management issues and suggests strategies for your medical office practice.
1. Patient Termination: The Medical Board of California advises that physicians must provide emergency care and prescriptions to a patient for at least 15 days before termination. Give notice of the termination in writing and include the termination date in the letter. Send the termination letter by certified mail, return receipt requested, and by regular mail. Be sure to keep the return receipt and a copy of the letter in the patient's medical record. Do not refill the patient's prescriptions beyond the termination date. [Reference: CMA ON-CALL document #0805, "Termination of the Physician-Patient Relationship," www.cmanet.org.]
2. Test Results Follow-up: Ensure the practice has a system in place for tracking all tests ordered. Follow up on test results that do not come back to the office. The physician should review and initial all test results prior to filing them in the patient's medical record. The physician should advise the patient of any abnormal test results.
3. Missed Appointments: The practice should have a formal missed appointment tracking system. Follow up with the patient by telephone to determine why the patient failed to arrive and to reschedule the appointment. Document missed appointments in the patient record. Send a letter to patients who repeatedly miss appointments, explaining the importance of follow-up care to their overall health. At the point established by your office policy, consider terminating the patient-physician relationship.
4. Scope of Practice: Medical office staff includes a variety of healthcare professionals. Never allow medical office personnel to act outside the scope of their job descriptions, licensures, or certifications. Do not refer to medical assistants as "nurses," and do not imply to patients that a member of your office staff is licensed or certified if he or she is not. Do not allow personnel to manage technology or medical equipment unless they have received appropriate training and, if necessary, are certified to operate the equipment.
5. Medication Management: During each visit, review the medication list with the patient (including all over-the-counter medications) and update accordingly. Provide the patient with a written medication list that includes dosage, directions for use, and side effects. There are many drug-drug and food-drug incompatibilities. Review a drug's side effects and interactions with the patient. If the office distributes medication samples, record the medication lot number in the medical record. In the event of a medication recall, the practice must have a system in place for identifying samples that have been distributed.
6. Documentation: Documentation is your primary defense in the event of a lawsuit - additionally, the medical record is the method for clinicians to communicate about the patient's plan of care. Remember to document the medical record objectively. Never point fingers at other physicians or clinicians. Do not impeach the integrity of the medical record by altering the record. Be sure to use approved abbreviations and to write legibly. If you use an electronic medical record (EMR), ensure that the system has a reliable backup and an appropriate disaster recovery program.
7. Dealing With a Disruptive Patient: Do not allow a disruptive patient to disturb your practice, to abuse office staff, or to threaten the safety of staff or other patients. Set boundaries and learn to say "no" to disruptive patients. If a patient becomes violent, call 911. Do not hesitate to terminate a disruptive patient from your practice.
8. Communication: Health literacy is an increasing risk issue for providers and patients. A patient's limited understanding of medical and prescription instructions results in increased risks for the provider and the patient. Ensure that the patient understands instructions. Document the name and relationship of anyone acting as a patient's translator. Consider using the Ask Me 3 communication tool for your patients. Ask Me 3, a free educational program sponsored by the National Patient Safety Foundation, is available at www.askme3.org.
9. Patient Satisfaction: Listen to your patients, and obtain their input to learn about potential opportunities for improving your office practice. Review and evaluate all complaints with your staff.
10. Medical Record Retention: The California Medical Association (CMA) has concluded that while a retention period of at least 10 years may be sufficient, it recommends that all medical records be retained indefinitely or, in the alternative, for 25 years after the last date of treatment. Destroy medical records appropriately, and maintain an inventory of all records destroyed. [Reference: CMA ON-CALL document #1160, "Retention of Medical Records," www.cmanet.org.]