Among the factors that inf luence the safety of ambulatory care and the liability risk levels of office-based physicians, three of the main ones are:

The level of communication with other healthcare providers about patients’ care; the effectiveness of office follow-up processes; and the attention given to documentation of telephone calls.

The following tips may help

physicians and office staff

members increase patient safety

and lower liability exposure

related to these factors. >>

Risk Management, PMSLIC Insurance Company and the NORCAL Group

Karen D. Davis, MA, CPHRM

Tips for

Lowering Ambulatory-Care

Risks

MANAGING PROFESSIONAL RISK

PRACTICE MANAGEMENT

AMBULATORY-CARE RISKS

Managing Professional Risk is a quarterly feature of NORCAL Mutual Insurance Company and the NORCAL Group. More information on this topic, with continuing medical education (CME) credit, is available to NORCAL Mutual insureds. To learn more, visit www.norcalmutual.com/cme.

NORCAL

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Communication with Other Healthcare ProvidersWhen you refer a patient to another physician, have some mechanism in place to determine whether your referral recommendation has been carried out and the patient has been seen by the recommended consultant (or another physician of the patient’s choice).

Communicate in writing with the consultant about the requested consultation. An effective way to convey significant details to another physician is to prepare a “fact sheet” with the patient’s clinical information and your impression.

After your patient is seen by a consultant, you and the consultant should establish who is responsible for which aspects of the patient’s care and who will order further testing and consultations if necessary. If there is a question about what you or the consultant will do, you should take the time to communicate physician-to-physician and to document the understanding you reach in your discussion.

Effectiveness of Follow-up ProcessesSystematically monitor compliance with appointments. Establish a process whereby a designated staff member reviews all no-show appointments to determine which patients must be called and rescheduled. Document no-shows, along with the steps taken to contact the patient and reschedule the visit.

When a patient is advised to undergo a test, three areas of concern require follow-up: Has the patient complied with the recommendation? Have test results been

received and reviewed by the ordering physician? Has the patient been notified about the results? An appropriate follow-up system provides answers to these questions.

Patients should not be solely responsible for making appointments for tests, to see consultants or for calling the office to obtain results. You should assist patients in making appointments in order to be assured that the appointment has been made. It is also prudent to notify all patients of all test results (rather than just reporting abnormal results). Such a policy helps close each testing loop and reduces the possibility of patient information “falling through the cracks.”

Your follow-up system for tests should not only confirm receipt of test results but also ensure that you review the results. The review should be timely. A test result should never be filed until you (as the ordering physician) have personally reviewed, dated, and initialed it. Without such a method, a positive result can be accidentally misplaced or filed away before you review it or the patient is notified. If the patient later alleges that harm occurred as a result of a delay in diagnosis and treatment, the mishandled test result may well be viewed as concrete evidence of negligence. Documentation of Telephone CallsGenerally, the types of telephone calls from patients that should be documented include: clinical questions and what advice was given, calls for prescriptions or renewals, after-hours calls, and calls to an on-call physician. Calls to patients that should be documented include: calls to share test results, calls to contact no-show patients, calls to give patients

instructions or to advise about further access to care, and unsuccessful attempts to contact patients.

Telephone contacts should be documented in the appropriate medical record. If your office simply keeps a call log, information about a specific call can be difficult to retrieve. The facts surrounding a call are not readily available if they are recorded in a call log; thus, using a log can be detrimental if a malpractice claim is filed and your office must produce information about the patient’s interactions with the practice.

You should have a system for documenting all after-hours phone calls. You can use telephone call forms or a tape recorder or dictation machine to record patient name, time of and reason for the call, and your advice or action. When the call is from a patient, the information should be added to the patient’s chart as soon as possible.

Giving clinical or medical advice over the telephone without timely, face-to-face follow-up increases your liability exposure. Prescribing over the phone is also risky, as it requires you to assess the patient sight unseen. You should not prescribe for a patient unknown to you without seeing the patient. It is also prudent to have established parameters as to when prescriptions will be renewed by phone.

Consider developing the preceding suggestions as policy and including them in a policy manual. Make sure all employees review your policy and consider asking them to sign off yearly that they have been advised of the policy and understand it.

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