By Lesley Viner, MS, Assistant Vice President, Risk Management, for the Reporter Q3 2019.
To improve services and better understand policyholders’ needs and concerns, the Risk Management Department analyzes trends on an annual basis. Information is collected and examined in the following areas:
1) the most common risk management recommendations made after practice reviews;
2) the most requested seminar topics by physician groups; and
3) the most common phone and e-mail inquiries received by physicians and their staff members throughout the year.
The following is a summary of the 2018 results.
Practice review recommendations
The 10 most frequent recommendations made by TMLT risk managers after evaluating physician practices include:
- Electronic Health Record (EHR) default to normal or negative:
Update the medical record to reflect the patient's current complaints and check for unintended system defaults to normal or negative. The review of systems or exam should not conflict with the history of present illness (HPI) or chief complaint. Contradictory information in the record can be a challenge in the defense of a claim or medical board complaint.
- Preformatted text or templates:
Preformatted text or templates in the EHR should be edited. When using preformatted text or templates in electronic health records, edit entries to ensure the record accurately reflects the care delivered. Inconsistent information in the record, due to prepopulated text, can be problematic in the event of a claim.
- Tracking and follow-up:
The practice should have a consistent process in place to track consultant referrals, lab, or diagnostic tests. When patients are referred to consultants or to outside labs or testing facilities, a tracking system can help ensure the patient is seen and results are received in a timely manner.
- Blank areas in records:
Templates or forms used to document patient encounters should be completed fully. All blank or incomplete areas on forms or templates should be filled in or marked "N/A." Areas left blank or unanswered may be open to conjecture when reviewed by others. To reduce blanks within an EHR, practices should review and edit templates, tailoring them to the physicians’ specialty and needs.
- Patient return visit:
Medical records should include the timeframe for the patient‘s return visit. It is important, for the continuity of patient care, to document when the patient should return for a follow-up visit. This enables office staff to schedule the visit, preventing possible allegations of failure to diagnose and treat.
- Documentation of physician review:
Incoming consultant reports, diagnostic results, or outside tests should include documentation of physician or provider review. Timely review should be documented in the patient’s record before scanning or filing. This documentation demonstrates that results were seen promptly. When appropriate, documentation of actions or inactions on specific results and decision rationale should also be noted in the record.
- Informed consent for List A procedures:
Written informed consent must be obtained for those procedures identified by the Texas Medical Disclosure Panel (TMDP) List A. An informed consent discussion, outlining the risks and benefits of List A procedures, should occur and be documented and filed in the medical record. As required by Texas law, providers must disclose specific risks, as determined by the TMDP, and consent forms should include these risks. Detailed documentation of the informed consent discussion, accompanied by an appropriate signed consent form, can enhance the physician’s defensibility should an adverse event occur.
- Cloned or copied records:
Ensure that patient history and other elements of the medical record are appropriately updated at each patient visit. Records that reflect incorrect history, issues that no longer affect the patient, or outdated exam information can compromise the defense of a medical liability claim.
Standard 10 of the Texas Medical Board’s (TMB) rule 165.1 states that "all non-biographical populated fields, contained in a patient's electronic medical record, must contain accurate data and information pertaining to the patient based on actual findings, assessments, evaluations, diagnostics, or assessments, as documented by the physician.” While copying text from one visit to the next may save time, make sure the record entries are accurate.
As required by federal law, all health care providers who dispense vaccines must provide a Vaccine Information Statement (VIS) before administration. In addition, health care providers should document the edition date of the VIS and the date of injection.
- EHR policies and procedures:
The practice should have written policies for EHR security and processes, and policies should be kept current. Federal privacy and security rules require that practices develop protocols to protect the integrity and security of electronic protected health information (PHI).
EHR policies may include topics such as documentation of a privacy and security risk analysis, privacy and security training for staff, and other protocols to safeguard PHI. Policies should be signed by the physician(s) and include implementation and revision dates. Staff members should sign and date an acknowledgement of policy review and understanding.
Continuing medical education (CME) programs
The most requested CME seminar topics in 2018 included:
- Anatomy of a lawsuit;
- EHR pitfalls;
- Termination of the physician/patient relationship;
- A review of closed claims;
- Risk management in anesthesia;
- Cyber risk management;
- TMB complaints;
- Physician resilience/stress and burnout; and
- The opioid epidemic.
The most common phone and e-mail inquiries received from policyholders involved the following issues:
- termination of the physician/patient relationship;
- general office inquiries (policies and procedures or call coverage);
- medical records;
- selling, closing, or leaving a practice;
- regulatory and TMB concerns;
- prescription issues;
- patient visits;
- request for sample forms/letters; and
- care of minors.
TMLT encourages policyholders to engage in risk management activities including practice reviews, CME programs, phone or e-mail consultations, and the use of sample forms, tools, and resources. Our Risk Management Department is committed to providing customized services for physicians, with the goals of continually enhancing patient safety and reducing medical liability risk.
Contact the Risk Management Department at 800-580-8658 for more information regarding services and scheduling.
This article is included in the Reporter Q3 2019.