Top 10 Risk Areas: How Does Your Practice Stack Up?

It’s easy to assume that malpractice lawsuits arise from major mistakes or gross negligence. But statistics show that most cases stem from simple oversights and common errors that could be prevented.

The following Practice-Saving Checklist can help you quickly pinpoint malpractice weaknesses in your practice. It’s an easy guideline to help you evaluate your current procedures and implement simple solutions to dramatically lower your risk of a lawsuit.

1. Do your records provide a comprehensive patient history documenting your interaction with the patient and facilitating the continuity of care if another provider intervenes?

YesNo

GOOD. ACTION REQUIRED. Your best defense in a malpractice case is your documentation. Entries should accurately describe the patient's history, diagnosis and deatils of the treatment plan. Thorough documentation is the basis of communication among the patient's healthcare providers.

2. Do you regularly use informed consent forms for all invasive procedures?

Yes No

GOOD. ACTION REQUIRED. True informed consent is more than a form. It's a process of educating patients. Before any treatment protocol is implemented, your patient should always understand the following: (1) the nature of the treatment (2) all material risks for the treatment (3) the possibility that risk will occur (4) alternative treatments available and associated risks and (5) consequences of going without the recommended treatment. Your patient's signature on an informed consent form simply serves as documentation that you've done a thorough job of educating your patient.

3. Is your practice HIPAA compliant?

YesNo

GOOD. ACTION REQUIRED. Review your office policies, procedures and practices along with federal HIPAA guidelines. Be aware of the requirements to meet HIPAA standards for administrative, technical and physical aspects of your practice. Adapt global HIPAA policies and procedures to your individual practice. Learn where the external and internal sources of protected health information are located. Train employees on your policies and procedures. Perform due diligence on various third party risk assessors and partners.

4. Do you have a process for handling medical emergencies in your office?

YesNo

GOOD. ACTION REQUIRED. Emergencies can happen in the best practices. Be prepared in case the worst happens. If you have emergency equipment afavailable, ensure that your staff is trained on its correct use. Mock drills can be held and staff should know where the equipment is located. Each staff member should know and practice their responsibilities so they are prepared in the event of an emergency. If an emergency kit or cart is available, it should be inspected and resupplied on a regular basis.

5. When terminating a physician/patient relationship, do you notify patients in writing?

YesNo

GOOD. ACTION REQUIRED. If you decide not to treat a current patient, proper documentation of your decision can reduce your risk of later claims, alleging a doctor-patient relationship still existed. Any healthcare concerns should be highlighted while clearly stating that you will not be responsible for treatment of that patient after the reasonable time frame suggested in your letter. The letter should be sent by certified mail, return receipt requested and by regular mail.

6. Do you consistently create patient records at the time of treatment?

YesNo

GOOD. ACTION REQUIRED. Experts generally point to patient records as one of the most common weaknesses in today's busy practices. Timely documentation, completed within 72 hours of the visit, should be considered an integral part of patient care.

7. Do you review patient records from other providers before treatment?

YesNo

GOOD. ACTION REQUIRED. Providing quality care to your patients includes being knowledgeable about their previous medical issues. Document your review of records in the patients' chart. If you choose not to keep any portion of the records sent, document the following: what was done with them (shredded or returned to patient) and why you chose not to keep the records.

8.Do you utilize a tracking system to know when tests or consults are ordered, received and ultimately communicated to the patient?

YesNo

GOOD. ACTION REQUIRED. Missed test results, labs or consults can led to a diagnostic error an delay in treatment. Patients can fall through the cracks if you are not using a tracking system to alert you to outstanding items. The patient must remain active in the tracking system until one of two potential outcomes occurs: documentation of informed refusal to follow medical instructions or documentation that the patient has been contacted with results and provide with advice or instructions.

9. Is there a system in place for triaging and documenting phone calls?

YesNo

GOOD. ACTION REQUIRED. Telephone triage is essential to the delivery of quality care. Only qualified staff designated by the provider should provide telephone triage services. Office protocol should require documentation of all clinically relevant calls. You can avoid disagreements about what was said and to whom with clear, timely, thorough documentation.

10. Are there protocols in place for staff to follow in handling a disgruntled or angry patient?

YesNo

GOOD. ACTION REQUIRED. Being confronted by an angry patient can be uncomfortable and stressful. For a successful interaction with an angry or disgruntled patient, practice these communication steps: (1) stay calm; (2) acknowledge the patient's anger; (3) accept responsibility for the problem; (4) ask questions; (5) restate the problem; (6) develop solutions together; (7) exceed expectations.

You may want to speak with a risk manager about any items you marked “no.” Our experienced risk managers can help you assess your situation and suggest solutions you may want to implement to help minimize risk.

Call the Risk Management Hotline at 1-888-336-2642 or contact us via email.