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Risk Management Guidelines for the Physician Office

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Risk Management

Risk Management Defined
Risk Areas in a Physician Office
Goals for a Risk Management Program
Adverse Events – Reporting and Investigation
Billing and Collection Practices
Discharging a Patient from Your Practice
Merging or Closing a Practice
Patients Who Do Not Adhere to Their Treatment Plans
Risk Financing
Treating Minors

Communicating With Patients and Other Providers

Office Culture
Making a Positive Impression
    Remember Common Courtesies
    Listen
    Ensure Understanding
    Follow Through
Patient Satisfaction
    Patient Satisfaction Surveys
Patient Triage
Effective Telephone Communication
    Phone Set Up
    Giving & Receiving Medical Information
    Handling Prescription Refill Requests
    What to Document
    Answering Service
    Monitor Trends
Communicating Test Results is Critical
Email Communications
Shared Decisions, the Dialog of Consent
Communication Tools
    Patient Agendas
    Practice Brochures/Websites
    Visit Summaries
    Team Huddles
    Posters
    Handouts
Communicating Under Stress
    Anger and Violence
    Disclosing Difficult Information/Apologizing
    Patient Complaints
    Patients Who Record Conversations with You
Communicating With Other Providers
    Consults and Referrals
    For referring physicians
    For consulting physicians
    Hallway Consults

Follow-up Systems for the Physician Office: Overview

Tracking Systems
How to Develop Manual Tickler System
Documentation Which Supports Your Tracking System
Patients Who Require Special Tracking

Human Resources

Hiring
Credentialing and Employee Records
Monitoring and Coaching Your Staff
Policy/Procedure Manual
Physician Coverage
Special Circumstances
    Locum Tenens
    Manufacturer’s Representatives
    Students in the Office as a Learning Experience

Miscellaneous Legal and Regulatory Issues

Abuse, Neglect, and Domestic Violence
    Children
    Adults
    Domestic Abuse
Advance Directives
The Americans with Disabilities Act (ADA)
Contract Management
Corporate Compliance Program
Basic Compliance Program Elements
Handling Medical Board Complaints and Malpractice Claims
    Malpractice Claims and Summons
    Medical Board Complaints
Health Insurance Portability and Accountability Act (HIPAA)
Informed Consent
Clinical Trials
Managed Care
Mandatory Reporting to State Agencies
OSHA
Subpoenas and Other Requests for Medical Records
Vicarious Liability (Apparent Authority)

Medical Records

Documentation Guidelines
    Avoid Insufficient Documentation
    Understand Documentation Mechanics
    Prevent Inappropriate Documentation
    Record Handling
Chart Auditing
    Chart Structure
    New Patients with Old Charts
    Record Destruction
Unplanned Record Destruction
    Retention of Records
    Storage of Old Records
Release of Records
    Subpoenas for Medical Records
    Court Orders
    Release of Original X-Rays
Electronic Health Records (EHR)
Electronic Medical Records: Patient Safety & Risk Management Guide

Medication Safety

Medication Storage and Control
Medication Lists
Allergy Documentation
Prescriptions
Patient Drug Education
Medication Samples
Administering Vaccines, Medications, and Allergens in the Office

Office-based Procedures and Diagnostics

On-site Procedures
Primary Areas of Risk
    Patient Screening and Selection
    Anesthesia Plan of Care
    Staff Competencies and Credentialing
    Informed consent
    Pre-op procedures
    Intra-op procedures
    Post-op period
    Post-discharge
    Emergency Equipment/Supplies
    Process for Emergency Transport
    Written Policies and Procedures
    Performance Improvement/Quality Assurance activities
Cosmetic Procedures
On-Site Diagnostics

Office Safety

Medical Equipment
Emergency Preparedness
Injection Safety
Infection Control Recommendations from the CDC
Office Safety Manual
    An Office Safety Manual
         • Policy & Procedure: Defibrillators/AEDs & Crash Carts
         • Policy & Procedure: Electrical Safety
         • Policy & Procedure: Electronic Equipment & Systems Protection
         • Policy & Procedure: Emergency Response
             • 911 Poster
             • RACE fire safety diagram
         • Policy & Procedure: Fire Safety
         • Policy & Procedure: Hazardous & Medical Waste
         • Policy & Procedure: Infection Control
         • Policy & Procedure: Investigating Events in the Office Practice
             • Event/Complaint Report
             • Instructions for Completing Event/Complaint Report
         • Policy & Procedure: Medical Equipment Management
             • Medical Equipment Tracking Log
         • Policy & Procedure: Security Management
         • Environmental Safety Self Assessment
         • Infection Control Self Assessment
         • Helpful Links for Office Practices

© Copyright 2012 Princeton Insurance. All Rights Reserved.
RISK MANAGEMENT GUIDELINES FOR THE OFFICE PRACTICE: March 2006 - Revised February 2012

The Guidelines are neither intended to provide legal advice, nor to serve as a professional standard. The contents are only for purposes of information and education.

Healthcare law is complex and highly regulated. The law changes frequently and because these changes can be significant, you should always check with appropriate professionals to stay fully abreast of the current laws that impact the delivery of healthcare services.