Every EHR system has an audit trail. The timeline is no longer a guessing game. Gone are the days of using handwriting experts to try to determine when and by whom an entry was made in a patient’s chart. Forensic IT experts can now review the metadata contained within the EHR to determine everything tha...
Few medical errors are as indefensible as those involving patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure performed that was intended for another patient. These “wrong-site, wrong-procedure, wrong-patient errors” (WSPEs) are termed ...
When an unsolicited test result is received regarding an established patient of the practice, it should be handled the same way as one that was personally ordered. Contact the patient, notify the ordering physician, and, if appropriate, arrange for needed follow-up care. Do not automatically assume normal res...
Last month, we discussed the importance of the informed consent discussion to prevent malpractice claims. As a follow-up, remember that it is the discussion that takes place between the provider and the patient (or patient’s legal representative) that constitutes the basis for the consent to be &l...
Informed consent is often the most important discussion that physicians will have with their patients, but unfortunately, it is sometimes viewed as merely obtaining a signature on a pre-printed form. While lack of informed consent is rarely the central issue in a malpractice lawsuit, it is almost always...
Governmental shelter-in-place orders and the need to avoid unnecessary physical contact driven by the coronavirus pandemic have caused many providers and patients to suddenly turn to the virtual world to provide and receive care. While this has generally been good for the healthcare system and patient s...
When practicing telemedicine, keep in mind that the medical services are being rendered at the patient’s location. Therefore, the provider must: be licensed in the state where the patient is located; be familiar with the standard of care in the patient’s location and comply with th...
An old Chinese proverb says that “the faintest ink is more powerful than the strongest memory.” Timely documentation is critical in order to ensure an accurate and complete record of the patient encounter. Office notes and dictated procedure notes should be completed, reviewed and signed within 2...
Physicians and other clinicians are well aware of the legal obligation to provide informed consent for treatment. A fundamental component of consent is providing the patient with sufficient information to make an informed decision about the risks, benefits, and alternatives of the proposed treatment. Clearly,...
Medical practices are often challenged with how to handle a missed appointment during which follow-up care or treatment was to be provided. It is important that the practice have a procedure to ensure that no-shows and cancellations are communicated to the treating provider and any actions taken are documente...
Each year, ECRI Institute – a nonprofit organization that researches approaches to improving patient care – identifies TOP 10 Patient Safety Concerns. This list identifies key areas to “support health care organizations in their efforts to proactively identify and respond to threats to ...
From time to time, physicians and other healthcare providers find themselves in receipt of diagnostic test results they did not order for their patient, or for individuals who are not even patients of the practice at all. Such results could be anything from laboratory or pathology reports to scree...
Like most busy physicians, you probably dread the monthly team meeting to take a closer look at office processes and systems. In a day filled with playing phone tag, wading through e-mails, dealing with unexpected patient situations, following up on tasks and documenting, where’s the time to squeez...
Increasing concerns about the quality of healthcare have arisen as a result of the public perception that cost-cutting measures have caused premature discharge and clinical mismanagement of patients. Changes in healthcare coverage have generated concerns that medical care has become a profit-motivated busines...
Have you or your staff been “drifting into unsafe habits?” Do you follow the template generated by your EHR without questioning its validity or applicability to the patient in front of you? Do you ignore alerts and other prompts? Do you ask only close-ended questions of patients such as, “Ar...
As healthcare evolves, so do patients’ expectations. Payers are changing reimbursement strategies to focus on value-based care, therefore patients' experiences and subsequent reviews of those experiences can affect the practice’s level of reimbursement. Understanding patients’ opinions and e...
Distractions and interruptions are a fact of life in today’s healthcare environment, but that doesn’t mean a practice should simply accept them and the threat they pose to patient safety. Identifying the sources and frequency of distractions and interruptions allows for implementation of strategie...
Electronic Health Records offer the potential for vast improvement in continuity of care, legibility and accurate recordkeeping. However, to most practitioners, that goal seems light years away. This is due to many factors out of the user’s control such as technology, design and integration issues. The ...
Last month, the CDC issued a letter to healthcare providers asking for help to ensure patients receive influenza vaccines by the end of October. The letter states “…To avoid missed opportunities for vaccination, providers should offer vaccination during routine health care visits and hospitalizat...
The adage about “people who live in glass houses” still holds true. Jousting usually occurs when another healthcare professional intentionally or unintentionally either verbally or in the medical record makes disparaging comments about other providers, nursing staff, equipment, EHR or administrat...
At SVMIC, we’re often asked if a practitioner can utilize the patient portal to notify patients of lab/test results that are normal and require no follow-up. The short answer is yes, you can use your patient portal to communicate lab/test results that are normal, require no immediate attention and are n...
Tempting as it may be, think twice before accessing medical records if you receive a notice of intent to sue or are served with a lawsuit. An electronic health record (EHR) system tracks activities and records the information in metadata—the “data about data”—o...
At the UT College of Medicine, rising third-year medical students usually begin their clinical rotations during the first week of May. In preparation, UT has historically educated these students in risk management, where they learn, among many other things, the importance of their patients’ knowin...
Do you have a procedure for handling a missed appointment during which follow-up care or treatment was to be provided? To avoid patient harm and a claim of missed or delayed diagnosis, it is important that practices have a procedure to ensure that no-shows and cancellations are communicated to the treating pr...
Spring has sprung, which means spring cleaning for many of us. It may also be a good time to retool your office tracking procedures, as diagnostic error accounts for one-third of SVMIC’s paid claims. Tracking system failures are a primary factor in diagnostic error. Maintaining a system within each offi...
One of the simplest tools for improving your communication with patients is intentional or "active" listening. When a new mother brings her baby to the office, listening to her description of the problem often provides that subtle clue a physical examination may not have revealed. Not all medical interactions...
According to the Food and Drug Administration (FDA), it regulates one trillion dollars’ worth of products each year or approximately 20 cents on every dollar spent in the U.S. When there is a serious problem with a product, the FDA would like to alert you immediately. The alerts contain actionable infor...
The term “culture” in your medical practice shouldn’t only mean a lab test to identify microorganisms. Even if you’re not aware of it, there is an environmental culture within your practice that affects productivity, staff performance and patient safety. Culture is a system of shared v...
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