What every physician needs to knoW:

top 10 risk management recommendations

about

• TMLTriskmanagementstaffconducton-sitepracticereviewstohelpphysiciansdetermineandaddresstheirmedicalliabilityrisks.

• In2016,riskmanagersreviewedmorethan2,000physicianpractices,andgavethefollowing10recommendationsmostfrequently.

1 document after-hours calls

• Documentingafter-hourscallsandanyinstructionsgiventopatientsisimportantforcontinuityofcare.

2 ehr policies & procedures

• Thepracticeshouldmaintainup-to-date,writtenpoliciesforEHRprocesses.Policiesmayincludeprivacyandsecurityriskanalysis,privacyandsecuritytrainingforstaff,andotherprotocolstoprotecthealthinformation.

practice policies & procedures3

• Keepacurrentpolicyandproceduremanualforpatientcare.Themanualshouldincludeinformationoncommunicatingwithpatients,medicationrefills,ordertrackingsystems,missedappointments,andemergencyprotocols.

4 document names of others

• Itisimportanttonotewhoispresentduringapatientvisitbecauseimportantinstructionsandeducationregardingthepatient’sassessmentandtreatmentarediscussed.

edit pre-formatted text 5

• Whenusingpre-formattedtextortemplatesinEHRs,editentriestoensuretherecordaccuratelyreflectstheclinicalcaredelivered.Inconsistentorcontradictoryinformationintherecord—duetodefaulttextorcloningofinformationfromothervisits—couldleadtoerrors.

document folloW-up requests

• Itisimportantforthecontinuityofcaretodocumentwhenapatientshouldreturnforafollow-upvisit.Thisenablesofficestafftoschedulethevisitandmaypreventthepatientfromfallingthroughthecracks.

6

revieW and update medications

• Prescriptionandover-the-countermedicationsshouldbereviewedandupdatedintherecordateachvisittomonitorcomplianceandhelppreventadversedrugreactions.Newpatientsshouldbeencouragedtobringallcurrentmedicationstotheinitialvisit.

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8 have a tracking system in place

• Whenpatientsarereferredtospecialistsortoanoutsidesourceforlabordiagnostictests,atrackingsystemcanensurethepatientisseenandtheresultsarereceivedandreviewed.

document patient phone calls

• Documentpatientphonecallsandanyinstructionsgiventopatients.Aswiththedocumentationofafter-hourscalls,thisinformationcanhelpthephysicianandsubsequentcaregiversintreatingthepatient.

9

document diagnostic

reports

• Documentingthephysician’sreviewofconsultantreports,diagnosticresults,oroutsidetestsdemonstratesthattheresultswereseeninatimelymanner.Whenappropriate,documenttheactiontakenonspecificresultsandthephysician’srationaleforthoseactions.

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protection for a neW era of

medicineabout tmlt:Withmorethan20,000healthcareprofessionalsinitscare,TexasMedicalLiabilityTrust(TMLT)providesmalpracticeinsuranceandrelatedproductstophysicians.Ourpurposeistomakeapositiveimpactonthequalityofhealthcareforpatientsbyeducating,protecting,anddefendingphysicians.www.tmlt.org

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