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• 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.
7
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.
10
protection for a neW era of
medicineabout tmlt:Withmorethan20,000healthcareprofessionalsinitscare,TexasMedicalLiabilityTrust(TMLT)providesmalpracticeinsuranceandrelatedproductstophysicians.Ourpurposeistomakeapositiveimpactonthequalityofhealthcareforpatientsbyeducating,protecting,anddefendingphysicians.www.tmlt.org
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