Documentation and Prescribing Issues for Non-Physicians
Many malpractice claims are brought against physicians, not because of inappropriate medical care, but because the documentation does not support an appropriate standard of care when a patient has an adverse outcome. Effective documentation is one of the most important patient care and risk management skills a healthcare professional can develop. One of the most significant components of a medical record, and just as important to the care of a patient, is the medication section. Staff play an integral part in keeping the medication flow sheet current and accurate and are often the front line contacts for patients requesting refills over the phone. Given the increasing focus on controlled substance abuse, physician prescribing habits are being scrutinized more closely. This is especially true in Tennessee where numerous laws have been enacted to govern the prescription of controlled substances. Prescribers and staff need to know these rules and how they pertain to them as well to ensure they do not run afoul of the law.
Because documentation and prescribing practices are such significant areas of importance to patient care and have substantial risk factors associated with them, this staff seminar will focus on both topics from the perspective of the non-physician.
Upon completion of this program, attendees should be able to:
- Recognize common documentation errors;
- Identify opportunities to improve documentation; and
- Understand Tennessee laws and rules related to prescribing as they pertain to the non-physician staff member.
Speaker: Stephen Dickens, JD, FACMPE
Stephen Dickens is a Risk Management Specialist at SVMIC. In this role, he works with physicians and their staff concerning areas of risk and practice operations. He has spent more than 20 years in a variety of healthcare leadership roles including medical group, hospital and home care administration. In addition to his role at SVMIC, he has served as Chair of the Medical Group Management Association (MGMA), past president of the MGMA Financial Management Society, Tennessee MGMA and Tennessee Association for Home Care. In addition, he is a Board Certified Medical Practice Executive and Fellow in the American College of Medical Practice Executives.