Risk Management Checklists: Healthcare Office Policies

MLMIC publishes Risk Management Checklists to assist insured physicians and facilities with policies and protocols in critical areas, including office policies. These checklists focus on specific risk management issues – maintaining patient confidentiality, tracking test results, following up on missed or cancelled appointments, using chaperones or scribes and handling patient complaints – that policyholders are likely to encounter in the healthcare setting.

We encourage you to review these checklists for risk management in healthcare office policies on a regular basis to promote patient safety and reduce potential liability exposure:

Maintaining Patient Confidentiality

Patient confidentiality breaches pose a significant risk in the healthcare setting. HIPAA and New York State laws govern your obligation to maintain the confidentiality of protected health information (PHI). Staff and providers must be aware that routine office practices, including telephone contact, verbal discussions and computer use, inherently carry the risk of patient confidentiality breaches.

View or download the checklist here: Maintaining Patient Confidentiality.

Tracking Patients’ Test Results

The receipt and review of test results are important aspects of patient care and safety in physician practices. Tests may not be completed, or results may be lost, overlooked or not received, leading to potential delay in diagnosis and subsequent liability exposure. Follow-up procedures should be an integral part of your practice and can help ensure that patients obtain the necessary testing, as ordered, and that results are received, reviewed and properly addressed.

View or download the checklist here: Tracking Test Results.

Follow-up of Missed or Cancelled Healthcare Appointments

A missed or cancelled appointment and the failure to follow up with or contact the patient may result in a serious delay in diagnosis or treatment. A well-defined process that includes provider notification and follow-up procedures in this situation will help ensure continuity of care and enhance patient safety.

View or download the checklist here: Follow-up of Missed or Cancelled Appointments.

Using Chaperones During Physical Examinations

Providers must recognize that, at any time, a patient can make a complaint to the Office of Professional Medical Conduct alleging that he or she was the victim of a provider’s sexual misconduct. The presence of a chaperone during intimate physical examinations may be beneficial to both the provider and the patient. First, it may provide reassurance to patients, demonstrating both respect for their concerns and an understanding of their vulnerability. Second, the use of chaperones can provide legal protection for the provider in the event of a misunderstanding or false accusation of sexual misconduct on the part of the patient.

View or download the checklist here: Using Chaperones During Physical Examinations.

Handling Patient Complaints Properly

Patient satisfaction is an integral part of providing healthcare, regardless of the clinical setting. Dissatisfaction with medical care may be a harbinger of medical malpractice litigation. When you receive a complaint about care, how you handle the situation may directly impact the potential for any future litigation. All physician practices should have a policy or protocol in place to address patient complaints.

View or download the checklist here: Handling Patient Complaints Properly.

The Proper Use of Scribes in Healthcare

As the use of electronic health records (EHRs) has become widespread, documentation practices and workflow patterns have changed significantly and have added to a growing clinical and administrative workload. The use of this technology has increased the amount of time necessary to complete medical record documentation and order entry.

One way that physicians have chosen to address these issues is through the use of scribes. Scribes originated in the fast-paced clinical setting of the emergency department (ED) as a way to reduce the time physicians needed to spend documenting care in an electronic format. The use of scribes has expanded from these roots in the ED to numerous other clinical settings. Scribes perform EHR data entry under the direct supervision of a licensed professional, freeing the physician or other provider to spend more time directly interacting with the patient.  As unlicensed members of the healthcare team, the recruitment, training and supervision of scribes is paramount in managing their use in all clinical settings.

View or download the checklist here: The Proper Use of Scribes.

MLMIC’s Risk Management Consultants are available to assist insured physicians and facilities in their ongoing efforts to identify and address areas of concern related to office policies. For guidance regarding a specific situation, please contact MLMIC’s Risk Management Department at (800) 275-6564.

In addition, policyholders can stay up to date on the latest risk management guidance and alerts by monitoring the MLMIC Insider, The Scope: Medical Edition, Healthcare Weekly and other MLMIC communications.