Frequently Asked Questions: General Topics
Our experts answer questions on topics that include requirements for medical record documentation, retention and storage, patient adherence, stolen prescription pads, and reporting an incident or a claim.
- Am I required to sign off on my documentation?
- Each provider is ultimately responsible for his or her medical record documentation, regardless of its origin—from dictation, a scribe, or an electronic entry. Therefore, providers should confirm review by signing off on all documentation.
Additionally, there should be guidelines governing medical record documentation and authorship:
- Keep a master list of names, initials, and signatures.
- Require the use of the full last name if staff members have the same initials.
- Allow only the owner of a signature stamp to use that stamp.
- Provide guidelines to the appointment staff for documenting in a medical record.
- What resources are available for state regulations of practice?
- Some states have specific guidelines that may be checked through your local board of medicine, state medical society, or the Medical Group Management Association (MGMA), or you can contact your patient safety risk manager at The Doctors Company.
- How long should medical records be stored?
- Some states have specific guidelines that can be checked through your local board of medicine. The Doctors Company recommends the following:
- Adult patients, 10 years from the date the patient was last seen.
- Minor patients, 28 years from the patient's birth.
- Deceased patients, five years from the date of death (may vary by state).
For more information about medical record retention, see our article “Frequently Asked Questions: Medical Records Issues.
- Do patients have to sign a release for their own medical records?
- Yes, absent a subpoena, any request for medical records requires a properly signed and dated HIPAA release form from the patient or from the appointed surrogate decision maker. In the case of a deceased patient, there should be evidence of the appointment of a surrogate.
- What should I do if I learn that a patient has stolen my prescription pad or altered his or her prescription?
- We recommend that you take the following steps:
- Confront the patient in an environment that is safe for you, your staff, and your other patients.
- Report the offense to your local police department.
- Contact the appropriate state agency.
- Review your office procedure for storing prescription pads.
- Is calling the Department of Patient Safety about a potential claim the same as reporting?
- No. The services provided by the Department of Patient Safety are available to you as a member of The Doctors Company for purposes of providing advice and resources. Your patient safety risk manager may suggest that you contact the Claims Department to discuss an event. For more information on reporting a claim, visit our Reporting a Claim page or see our article “Notification of an Incident or a Claim.
- What is my responsibility to a patient who fails to follow my recommendation for a diagnostic test?
- Remember to document the medical record when the patient is responsible for scheduling and does not adhere to the recommended treatment plan, including testing that is non-urgent. An example is when an annual patient is told to schedule a screening colonoscopy before returning for the next annual visit. In situations in which the follow-up is critical or more emergent, have the office staff schedule the appointment and report back if the patient is nonadherent with keeping scheduled appointments. For additional recommendations, please see our article “Laboratory and Diagnostic Test Tracking in Ambulatory Practice.”
If you order or schedule a test, you are responsible for all follow-through—including ensuring that the results are received, reviewed, reported back to the patient, and documented in the medical record. Your office should have a tracking/recall system in place to ensure that test results are not lost or overlooked.
- As a male provider, should I have a female chaperone present when examining female patients?
- Yes. Additionally, anytime there might be an awkward or uncomfortable situation with either gender, it’s a good idea for a chaperone of the same gender as the patient to be present during the examination.
- What measures should I take to ensure that my practice is covered when I hand off call to another physician?
- There should be a clear directive for after-hours calls. For example, “If this is an emergency, hang up and call 911 or go to your nearest emergency department.” For nonemergency calls, there should be an answering service or a method for contacting the physician who is on call in your absence. Additional recommendations for handing off call to another physician:
- Note that the on-call physician should be the same specialty as you.
- Ensure that the on-call physician has current medical malpractice insurance.
- Debrief the on-call physician before and after you hand off the call responsibility.
For information regarding locum tenens, read “Arranging Locum Tenens Coverage.”
- Can I dismiss a patient from my practice at will?
- Discharging a patient from a practice should be evaluated on a case-by-case basis. You should not adopt a blanket policy, as there are criteria to be met or evaluated. Please contact us to receive an information packet containing sample letters and criteria.
- If I refund money or adjust a bill for a dissatisfied patient, is it considered an admission of liability?
- Not necessarily, but every situation should be evaluated individually. There are factors to consider from professional liability and compliance standpoints. In some situations, it may be viewed as a “courtesy” gesture and may be a positive factor in the defense of a claim. Other situations might warrant the use of a release of claims form. It is important to review your contractual agreement for compliance with all insurance payer sources.
- Is it a good idea to keep personal notes for the purpose of refreshing my memory in the event of an adverse outcome?
- Healthcare providers sometimes think that memorializing events shortly after they occur may be helpful (and perhaps even cathartic), particularly when a medical error or an adverse outcome has occurred. Because personal notes may be discoverable by the plaintiff’s counsel in the event of a lawsuit, however, maintaining this type of documentation is discouraged.
- Is it okay for a nurse or other employee to witness the patient’s informed consent and make sure that the patient signs the form?
- Once the physician has met his or her duty in the informed-consent process (i.e., having discussed with a patient the proposed procedure, including risks, benefits, and alternative treatment), a nurse or another delegate may obtain the patient’s signature on the form. If signing as a witness, the policy should clearly describe what the witness is “certifying.” However, before doing so, the patient should always be asked if he or she understands everything or has any questions. If there is any level of uncertainty expressed by the patient or his or her representative, the physician should address it directly.
- As a plastic surgeon, should I refuse to perform cosmetic surgery on a patient with whom I am not comfortable?
- When asked to perform elective surgery on a patient with whom you are uncomfortable, consider declining the patient. This news should be communicated in a manner that does not offend or anger the patient. It is certainly a better option than proceeding, only to have a dissatisfied or unrealistic postsurgical patient allege abandonment of care. For more information on patient selection, read “Patient Selection for Elective Procedures.”