Medical Records and Documentation

Dec 13, 2017
Disaster Preparedness for Your Medical Practice
Julie Brightwell, JD, RN
Recent fires, hurricanes, and floods nationwide have highlighted the importance of planning for disasters. Physicians are critical participants in disaster preparedness, ensuring that patient care and critical services are not interrupted—especially for at-risk individuals who may have special medical needs.

Dec 06, 2017
Electronic Health Record Closed Claims Study
David B. Troxel, MD, Medical Director, Board of Governors
Dr. Troxel provides a follow-up to his 2015 analysis of EHR-related claims.
From The Doctor’s Advocate

Nov 27, 2017
The Quality Payment Program: What You Need to Know for 2018
Beth Hickerson, Quality Improvement Advisor, Medical Advantage Group
The government recently announced 2018 changes to the Quality Payment Program. Many of these changes add flexibility and higher exemption requirements—welcome news to medical practices.

Sep 22, 2017
Five Best Practices to Meet MACRA Requirements by the End of the Year
Kim Hathaway, MSN, CPHRM, Healthcare Quality and Risk Consultant, The Doctors Company
As the end of the third quarter of 2017 approaches, practices that have not yet developed their Medicare Access and CHIP Reauthorization Act (MACRA) plan face great urgency to complete their plan—and those who have started may be feeling overwhelmed. Regardless of the reporting stage, these steps can help guide practices to succeed.

Aug 15, 2017
Objective Review of Potential Risks in a Medical Practice Can Be Beneficial
Ted Abernathy, MD, Managing Partner, Pediatric & Adolescent Health Partners
Ted Abernathy, MD, Managing Partner of Pediatric & Adolescent Health Partners discusses his experience with an assessment service offered by The Doctors Company which provided his practice with a comprehensive checkup of key areas and customized action plan.

Jun 14, 2017
Take Note: How Medical Scribes Are Trained—And Used—Varies Widely
Jeffrey A. Gold, MD, Professor of Medicine, Director of Simulation, Oregon Health and Science University
Though it is the fastest growing medical field, there is little regulation or standardization for training scribes. In this article, Jeffrey A. Gold, MD, of Oregon Health and Science University discusses the risks of using scribes based on a national survey of The Doctors Company's members.

May 22, 2017
MACRA Is a Marathon, Not a Sprint: How to Get Started Now
Robin Diamond, MSN, JD, RN, Senior Vice President of Patient Safety and Risk Management, The Doctors Company, with contributions by Kim Hathaway, Healthcare Quality & Risk Consultant, The Doctors Company
Physicians and practice managers may feel as if they’re being left at the starting line, there is still time to get in the MACRA race. This article has tips no matter where you are in the process.

Jan 05, 2017
The Faintest Ink
Carol Murray, RHIA, CPHRM, Patient Safety/Risk Manager II.
Complete and timely documentation of the medical record not only enhances patient care, but it also serves to strengthen your credibility if you are called upon to defend that care.

Oct 26, 2016
Optimize the EHR: Better Workflow Means Better Work-Life Balance
Chad Anguilm, Director of Professional Services, Medical Advantage Group. Medical Advantage Group is a wholly owned subsidiary of The Doctors Company.
There are tools that can streamline patient care and payment workflows in the electronic health record (EHR). By dedicating time and effort up front to optimize the EHR, physicians can get relief from administrative tasks, reduce duplicate entry of data, and save time by not having to search for records in multiple places.

Sep 23, 2016
The Perils of Printing an Electronic Health Record
David B. Troxel, MD, Medical Director, Board of Governors
A design flaw in an electronic health record system led to a malpractice claim against our insured cardiologist.
From The Doctor’s Advocate

May 06, 2016
Shared Responsibility for Preventing Malpractice Suits—Patient Interactions
Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management Education, and Carol Murray, RHIA, CPHRM, Patient Safety Risk Manager II.
The basic emotions leading to any medical liability action are surprise, disappointment, and anger.

Apr 04, 2016
Frequently Asked Questions: Medical Records Issues
Susan Shepard, MSN, RN, Director, Patient Safety and Risk Management Education, and Richard F. Cahill, JD, Vice President, Associate General Counsel, The Doctors Company.
Our experts answer frequently asked questions about medical records, such as length of retention, how to destroy hard copy paper records, and making backups of electronic health records.

Feb 23, 2016
Smile! The Doctor Is on Camera: The Pros and Cons of Recording Office Visits and Procedures
Rich Cahill, Vice President and Associate General Counsel, The Doctors Company
As smartphones have become ubiquitous—giving patients a video and audio recorder that’s always at hand—the question of whether or not these devices should be allowed in the clinic or hospital setting is becoming increasingly more common. The issue of allowing patients to record their appointments requires balancing potential privacy and liability risks with the potential benefits of improved patient recollection of instructions and treatment adherence.

Jan 06, 2016
Requests to Amend a Medical Record
Susan L. Marr, MSA, CPHRM, Senior Patient Safety Risk Manager, and Richard Cahill, JD, Vice President and Associate General Counsel.
When a patient requests an amendment to the medical record, the record should contain both the patient's request and the physician's response.

Oct 01, 2015
The Defensible Medical Record
Mark Gorney, MD, FACS (deceased), Governor Emeritus; Richard Cahill, Esq., Vice President and Associate General Counsel; and Susan Shepard, MSN, RN, Director, Patient Safety and Risk Management Education.
Most errors of medical judgment can be successfully defended with a complete and unaltered medical record.

Jun 01, 2015
Frequently Asked Questions: General Topics
Cynthia Morrison, RN, CPHRM, Patient Safety Risk Manager.
Our experts answer questions about topics such as dictation, storage of medical records, and stolen prescription pads.

Apr 06, 2015
Accurate Medical Records: Your Primary Line of Defense
Mark Gorney, MD, FACS (deceased), Governor Emeritus, Richard Cahill, JD, Vice President and Associate General Counsel, and Susan Shepard, MSN, RN, Director, Patient Safety Education.
It is critical for every physician to maintain meticulous records, because every medical malpractice suit can be won or lost based on the quality and content of the medical record.

Mar 24, 2015
Up in the Cloud: Is It Safe to Store PHI on Remote Servers?
David McHale, Senior Vice President and Chief Legal Counsel, The Doctors Company
Cloud storage is a convenient and cost-effective solution for medical practices and facilities, but precautions must be taken to ensure stored patient data is secure. This article has tips for choosing a cloud service provider.

Feb 05, 2015
Make Sure Your Medical Records Are Legible
Illegible patient records pose a risk to patient care, drain healthcare resources, jeopardize optimal reimbursement, and carry potential legal ramifications.

Jan 12, 2015
Electronic Medical Records May Cast Physicians in Unfavorable Light During Lawsuits
Keith L. Klein, MD, FACP, FASN
While the electronic medical record (EMR) has advantages, it also has introduced liability risks. EMRs can lead to lawsuits or result in a weak defense by casting the physician in an unfavorable light.

Dec 12, 2014
Curbside Consultations
Susan Shepard, MSN, RN, Director, Patient Safety Education, and Carol Murray, RHIA, CPHRM, Patient Safety Risk Manager II.
Physicians should be aware of the potential liability of informal "curbside" consultations, especially if expectations between the physicians are not clearly communicated.

Nov 01, 2014
Bad Outcomes: From Surprise and Disappointment to Anger and a Lawsuit
Mark Gorney, MD, FACS, Governor Emeritus, and Richard Cahill, JD, Vice President and Associate General Counsel.
Anger is by far the most common factor that moves a patient to file a malpractice claim.

Aug 01, 2014
Medical Records Disposition When Closing a Practice
Susan Shepard, MSN, RN, Director, Patient Safety Education.
The physician or physician group practice is responsible for making appropriate arrangements for the disposition of medical records when a practice closes.

Jun 19, 2014
Medical Record Retention
Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company.
A number of variables affect the length of time a physician should keep a medical record, such as state and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient record).

Oct 29, 2013
Malpractice Case Shows Risk from Physician Not Dating and Initialing Reports
Physicians must be certain that there is a process in place to ensure that no imaging, laboratory, or consultant's report is ever filed unless it has been dated and initialed by the physician as proof that it was reviewed.

Oct 25, 2013
Interactive Guide for Hospitals: Ancillary Care Areas: Medical Records
Medical records can create areas of potential malpractice exposure; this guide can help uncover risks.

Mar 28, 2012
Rx for Diagnosis
Focus on documentation and communication to help avoid breakdowns in the diagnostic process.

Oct 01, 2011
Signing Off and Signing Out: Lost in Translation
Ann S. Lofsky, MD (deceased), Anesthesia Consultant and Governor Emeritus; updated by Susan Shepard, MSN, RN, Director, Patient Safety Education.
Whether signing out to a colleague for the weekend or permanently closing a practice, handing off responsibility for patient care can create liability risks for the physician.

Jan 01, 2005
Upgrading the Chart—A Dangerous Practice
Mark Gorney, MD, FACS, Governor Emeritus (retired).
Alterations of medical records can make otherwise perfectly defensible cases almost impossible to defend.

Sep 01, 1999
Obtaining Informed Consent in a Teaching Situation
Mark Gorney, M.D., F.A.C.S., clinical professor emeritus of plastic surgery at Stanford University, is a founding member of The Doctors Company. Dr. Gorney, the company's medical director for 18 years, is now governor emeritus and senior consultant in plastic surgery.
It is important to inform patients when a resident physician will perform all or part of a procedure.

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