Analysis of investigations and prosecutions by the New York State Office for Professional Medical Conduct (OPMC) and the New York State Office for Professional Discipline (OPD) reveals simple lessons that can reduce the risk that physicians and other licensed healthcare practitioners will become the subject of professional conduct investigation or prosecution.
Incorporating these lessons into your professional practice can also enhance the quality of care rendered to your patients and enhance your ability to defend against professional liability claims:
Document the patient's chief complaint(s) or reason for the visit clearly in the medical record. Unfortunately, it is very common to open a practitioner's medical record and to be unable to grasp the reason for the patient's visit from a review of the notes. Because the chief complaint or reason for the evaluation can vary from visit to visit, the documentation should be updated in the progress note for each visit. Documentation of the chief complaint or reason for the visit then becomes an organizing foundation for the evaluation of the patient and the corresponding medical record documentation including with respect to the appropriate history, physical examination, diagnostic tests, treatments, procedures and follow-up.
Request authorization from the patient to obtain copies of relevant medical records from the patient's other healthcare providers and maintain communication with these healthcare providers. Important information relevant to management of the patient can be obtained by adhering to this practice.
Document in a clear manner all medications prescribed by you including dosages, frequency, and mode of administration. Also document all medications prescribed by other healthcare providers as well as all non-prescription medications being taken by the patient. It is helpful for the medical record to distinguish which medications you prescribed so that you do not inadvertently make it appear that you have prescribed medications that have, in fact, been prescribed by other healthcare providers.
Licensing authorities and the third party payers expect you to be able to justify the medical necessity of the services you provide to patients. Document in the patient's medical record the clinical basis for all patient management decisions including diagnostic tests, treatments, and prescriptions you order. If you can't think of a reason, that should be a red flag to you.
Plans for patient follow-up should be clearly documented at the end of each note. If the patient has completed evaluation and treatment that should be documented. If a patient does not follow-up as recommended, you should reach out to the patient as appropriate by phone inquiries and letters. Be sure that all patient contacts respect the confidentiality of the patient as required by state and federal law (HIPAA). All attempts at patient contact should be clearly documented in the patient's medical record.
When ordering diagnostic tests, be sure to follow up on the results and to take action, as appropriate, with respect to any results of concern.
It is essential to document discussions with the patient, including those relating to informed consent. Obtain written informed consent when appropriate.
Be sure that you are able to document your current clinical competence with respect to all treatment rendered to patients. Avoid providing evaluation and treatment that you are not qualified to provide. Consider the use of consultants when appropriate and follow up on their reports.
Finally, please note that the list of issues that can cause practice risk management problems is exhaustive, continuously expanding and beyond the scope of this article. When you encounter a problem for which your peers can not provide a basic, time-tested and common sense solution, it may be appropriate to seek the guidance of experienced legal counsel.
Note: This article is written for educational purposes only and does not constitute legal advice. You should consult with your legal counsel prior to acting on any of the educational information provided herein.
Alan Lambert, MD, Esq. is an attorney whose practice is dedicated to healthcare law. Dr. Lambert is admitted to practice law in New York and he is of counsel to the law firm of Butzel, Long, a professional corporation. For more information call 212-905-1513 or visit www.attorney-for-physicians.com
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