Documentation/EHR/Patient Records
Mar 22, 2023
Remote Patient Monitoring: Considerations for Telehealth Care
Remote patient monitoring is advancing the safety and accuracy of telehealth by filling in some gaps and increasing the types of care that can safely be provided in the home.
Mar 17, 2023
Obtaining Informed Consent in Teaching Institutions
Given the nature of teaching institutions—where individuals in training participate in patient care to varying degrees—the informed consent process is more complex and can present additional liability risks.
Jan 10, 2023
Interstate Licensure for Telehealth Can Fuel Practice Growth
Licensing restrictions were eased to facilitate care during the COVID-19 pandemic, and the new normal of greater state-to-state cooperation for access to care may endure in the coming years. Many restrictions still apply, however, and understanding them can help reduce risk.
Dec 12, 2022
Top Seven Tips for Telehealth
Although telehealth demand has declined since the peak of the pandemic, it continues to be an integral part of healthcare delivery. These top recommendations can help minimize risks for practices that provide care via telemedicine.
Oct 14, 2022
Disaster Preparedness for Your Office Practice
Natural disasters can occur suddenly and without warning, highlighting the importance of advance preparation. Make sure your practice has a plan in place.
Professional Education
Preventing Dictation Errors for Advanced Practice Clinicians
Emergency medicine providers are increasingly using voice recognition programs, such as Dragon Direct Voice Recognition Program, to document encounters. In reviewing closed malpractice claims, The Doctors Company identified dictation errors as a significant patient safety risk factor. The following case highlights the importance of timely recognition of dictation errors to ensure accuracy of the permanent electronic health record (EHR). This is particularly important when using a voice recognition program to document encounters in the busy emergency department. In this case, the voice recognition system was Dragon Direct Voice Recognition Program.
Sep 14, 2022
Recording Office Visits and Procedures: Pros and Cons for Healthcare Professionals
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.
Jul 28, 2022
Defensible Medical and Dental Records
Patient records, which serve a critical function in healthcare delivery and routine clinical operations, can provide key evidence in the event of a professional liability action.
Professional Education
Managing Patient Information: Strategies for Advanced Practice Clinicians
This program covers the patient information system, specifically documentation of patient information in the medical record. Many times, insufficient documentation results in the provider not being able to find information needed to guide clinical decision-making. Adequate documentation will enhance patient care by ensuring that patients receive the care necessary and may prevent a mis- or delayed diagnosis.
Video May 24, 2022
How Are Companies Like Apple Enhancing Electronic Health Records?
Richard E. Anderson, MD, FACP, Chairman and CEO of TDC Group, discusses Apple's move into healthcare and how it is having an impact on electronic health records.
Video Apr 28, 2022
How Will Analyzing Digitized Health Data Improve Health Outcomes Over the Next Decade?
Rob Kauffman, President of Healthcare Risk Advisors, part of TDC Group, explains why the increase in digitized health data will help improve health outcomes.
Video Apr 28, 2022
How Will the Amount of Digitized Health Data Increase Over the Next Decade?
Rob Kauffman, President of Healthcare Risk Advisors, part of TDC Group, discusses how digitized health data will dramatically increase over the next 10 years.
Video Apr 28, 2022
How Will the Use of Increased Health Data Cut the Cost of Insurance over the Next Decade?
Rob Kauffman, President of Healthcare Risk Advisors, part of TDC Group, notes that digitized health data will not only increase, but that it will lead to more customized patient care and a reduction in medical malpractice costs.
Apr 04, 2022
Strategies for Effective Patient-Assisted Telehealth Assessments
Physicians who practice telemedicine must consider the components needed to complete an effective remote assessment and plan ahead based on their specialty area and the patient’s presenting complaint.
Professional Education
HIPAA Fundamentals 2022–2023 Edition
This on-demand program provides an orientation to the basic requirements of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA gives patients many rights with respect to their health information. This program provides details on the HIPAA Privacy, Security, and Breach Notification Rules, such as the type of information that is protected, who must comply with the rules, and how patient information can be used and disclosed. This on-demand program includes many resources useful to staff training.
Mar 31, 2022
Interoperable Telehealth: Patient Safety Considerations
As efforts to connect patients and providers through telehealth continue, new delivery challenges have become apparent.
Mar 01, 2022
Nine Tips for Telehealth Clinical Documentation
Patient safety expert Sue Boisvert offers strategies to help providers address the unique documentation requirements created by telehealth care.
From
The Doctor’s Advocate
Feb 03, 2022
Informed Refusal
Documenting a patient’s refusal of test or treatment options is key to minimizing risk exposure.
Feb 02, 2022
Informed Consent: Substance and Signature
True informed consent is a process of managing a patient’s expectations. Every healthcare provider should develop an individual style and system, making it easier to avoid omissions and ensure consistency of application.
Nov 19, 2021
Documentation and Scope of Practice Issues in Dentistry
We analyze a case resulting in patient injuries and provide strategies that address documentation and staff protocols.
Aug 30, 2021
Telehealth: Frequently Asked Questions
As the evolution of telehealth continues, we address questions asked by medical and dental practices.
Aug 30, 2021
Healthcare’s Digital Revolution: Are We Ready to Reimagine the Work?
As we complete the first stage of the healthcare digitization process, we enter an era that will allow us to take advantage of new tools and ways of thinking to improve healthcare value.
From
The Doctor’s Advocate
Aug 16, 2021
ADA Accessibility for Healthcare Websites: How Practices Can Avoid Suits and Attract Patients
More than 3,000 digital accessibility lawsuits were brought in 2020—a 23 percent increase over the prior year. Healthcare practices and organizations, like businesses in many other industries, may be sued by web users who allege that there are site-use access barriers for those with disabilities and impairments that violate the Americans with Disabilities Act (ADA) and various state laws. Those caught up in these lawsuits can pay millions of dollars and be bound by the settlement to make specific changes to their websites.
Jul 21, 2021
Medical and Dental Record Retention
Having access to well-maintained patient records helps medical and dental professionals ensure continuity of care. It can also protect them against any future professional liability claims, licensing board complaints, and peer review inquiries.
Jul 16, 2021
Medical and Dental Record Issues: Frequently Asked Questions
We answer questions frequently asked by members about medical and dental records, such as length of retention, how to destroy hard copy paper records, and creating backups of electronic health records.
Jul 14, 2021
12 Strategies for Success With Open Notes in Healthcare: The Cures Act
On April 5, 2021, the 21st Century Cures Act prohibition on information blocking, also known as the requirement for open notes, went into effect. All providers who use electronic health records (EHRs) must comply, and patients must be able to access information in their EHRs “without delay.”
Jul 14, 2021
Open Notes in Healthcare: The Good, the Bad, and the Ugly of the Cures Act
Patient access to records is not new, and neither is the Cures Act, which dates to 2016. What is new is the requirement that patients have electronic records access that is fast and easy. This requirement is expected to result in more patients—still a small proportion overall, but more patients—accessing additional EHR information, including providers’ notes.
Jul 14, 2021
Open Notes: Healthcare Providers Should Prepare Now for 2023 and the Cures Act
The 21st Century Cures Act is a multiphase, multidomain piece of legislation whose requirements for healthcare providers are in effect now, and increase over time. Between pushing for electronic health record (EHR) interoperability and funding vast, ambitious research and data-collection initiatives, the act attempts to harness our collective data-gathering power for medical good.
Jul 14, 2021
What Open Notes Exceptions Does the Cures Act Allow?
As of April 5, 2021, patients must be able to access information in their electronic health records (EHRs) “without delay.” Unless an exception applies, clinical notes must not be blocked. But what exceptions to open notes does the Cures Act allow—or in some cases, require?
Jul 09, 2021
Requests to Amend a Medical or Dental Record
Patients have the right to request amendments to their medical or dental records, but providers have the right to determine if the changes will be made. Following the guidelines presented here can help ensure clear communication and documentation.
Jun 09, 2021
Telehealth Tune-Up: Preparing for Care After COVID-19
The pandemic prompted many practices to add telehealth services overnight. If your practice did, now is a good time to review the components of that implementation with these strategies for evaluating five key elements.
From
The Doctor’s Advocate
Professional Education
Dictation Errors in the Emergency Department
The Doctors Company identified dictation errors as a significant patient
safety risk factor. The following case highlights the importance of timely
recognition of dictation errors to ensure accuracy of the permanent
electronic health record (EHR). This is particularly important when using
a voice recognition program to document encounters in the busy
emergency department. In this case, the voice recognition system was
Dragon Direct Voice Recognition Program.
Mar 08, 2021
Are You Prepared for a Medicare Recovery Audit Contractor (RAC) Audit?
RAC audits can be triggered by innocent documentation errors. These strategies can help you assess your risk for coding and billing errors and establish compliance and practice standards.
Mar 03, 2021
Healthcare Cybersecurity During COVID-19 and Beyond: How to Protect Your Practice
Throughout the pandemic, cybercriminals have found additional opportunities to target the healthcare industry. Recent developments in ransomware sophistication and tactics are cause for added concern.
From
The Doctor’s Advocate
Feb 23, 2021
Telehealth from the Field: Case Study Involving Remote Monitoring Problems
Although remote monitoring technologies offer many benefits, they also present potential malpractice risks. Lessons from this case study highlight the importance of careful planning and preparation when incorporating technologies into patient care services.
Jan 06, 2021
Telehealth’s Newest Safety Risk: Distracted Patients
The rapid implementation of telehealth services has raised new challenges for physicians—including risks created by patients who are distracted during telehealth visits.
Dec 23, 2020
Orthopedics Case Study: The Danger of EHR Templates
This example of an orthopedic claim involving accurate medical record documentation illustrates the importance of exercising caution when using EHR templates.
Professional Education
HIPAA for Managers: The High-Level View
The program explores and defines HIPAA policies and procedures, business associate agreements, security assessment and analysis, training requirements, HIPAA compliance requirements, breach events, and informed consent.
Dec 14, 2020
How Medical Scribes Are Trained—And Used—Varies Widely
Though it is the fastest growing medical field, there is little regulation or standardization for training medical scribes.
Nov 23, 2020
Ransomware Attacks Against Healthcare Providers Are on the Rise
The proliferation of simple-to-use “ransomware-as-a-service” kits is partially to blame for the rise in attacks. Less technically skilled attackers are provided with free and easy-to-use tools and agree to share a portion of the ransom payment with the ransomware developer. These trends are of particular concern to the healthcare industry, as it is one of the most targeted sectors by cybercriminals. Small to midsized healthcare entities are inviting targets, because they often lack the cybersecurity sophistication to respond to attacks and are known to store, transmit, and process monetizable data.
Nov 04, 2020
Smartphones, Texts, and HIPAA: Strategies to Protect Patient Privacy
The very convenience that makes using smartphone technologies so inviting may also create privacy and security violations.
Oct 13, 2020
COVID-19 Administrative and Medical Record Documentation: Prepare for Future Lawsuits
For months, physicians and practice managers have been in crisis mode due to COVID-19 and have faced daunting challenges daily. What the future holds relative to the evolution of COVID-19 remains unknown, but it is certain that litigation for COVID-related claims is on the horizon and will impact physicians in all medical specialties and practice models.
Apr 29, 2020
The Faintest Ink: Documentation to Defend Quality Patient Care
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.
Apr 16, 2020
Shoulder Dystocia Documentation: Implementing a Protocol
Shoulder dystocia claims have traditionally been among the most problematic to defend.
Professional Education
General Surgery: Miscommunication and Inaccurate Documentation
Failures of systems often prevent physicians from making timely diagnoses. Failures may result when documentation is inconsistent or not thoroughly read. Other factors that hinder timely diagnosis include inadequate hand-offs or referrals.
Mar 06, 2020
Dealing With Online Patient Complaints
Physicians are understandably concerned about the consequences of negative posts about them on social media platforms.
Feb 25, 2020
Artificial Intelligence's Promise for Radiology: Reducing Risks
Bradley N. Delman, MD, MS, discusses the findings in a recent study of malpractice claims against radiologists, how artificial intelligence (AI) may help reduce the risk of patient injury, and—despite the benefits—the concerns he has with AI.
Nov 12, 2019
Closing or Relocating a Healthcare Practice
Physician practices close for many reasons, including physician illness or death or a decision to sell, practice solo, join another group, relocate, or retire. These patient safety and risk management tips can help make the transition easier.
Oct 31, 2019
The Algorithm Will See You Now: How AI’s Healthcare Potential Outweighs Its Risk
A third of U.S. physicians are already using artificial intelligence (AI) in their practices, and many believe there is ample reason to think this advanced technology can help address diagnostic errors—the largest cause of malpractice claims. However, there are still unresolved questions about the risks.
Aug 27, 2019
Electronic Health Records Continue to Lead to Medical Malpractice Suits
We analyzed 216 medical malpractice claims that closed from 2010 to 2018 in which EHRs contributed to patient injury. The pace of these claims grew, from a low of seven cases in 2010 to an average of 22.5 cases per year in 2017 and 2018. As EHRs approach near-universal adoption, they may become a more prevalent source of patient safety risk.
Jun 12, 2018
Digital Medicine and the Future of Healthcare
The digitization of medicine is transforming the entire healthcare system—new technologies like mobile apps and wearables bring both benefits and risks, patient access to healthcare is evolving, EHRs have created new patient safety risks, and artificial intelligence is evolving to play a role in future patient care.
Video Nov 06, 2017
How to Reduce the Safety Risks of EHRs
Don't just rely on technology. It is vital that you have processes in place for auditing, backing up, and cross-checking data in your electronic health record (EHR), according to Lily Talakoub, MD, FAAD, of McLean Dermatology and Skincare Center in McLean, Virginia, and The Doctors Company's EHR Closed Claims Study. Dr. Talakoub discusses the biggest risks identified in the study, including that imaging and labs are often not found or not followed up on in the EHR or errors with copy and paste, and shares the processes that her office uses to lessen these risks.
Video Oct 25, 2017
The Dangers of Templates in EHRs
The role of electronic health records (EHRs) as a contributing factor to malpractice claims has increased over the past three years—with incorrect use of templates being a top risk factor. This case study from The Doctors Company’s EHR Closed Claims Study illustrates that danger.
Video Oct 23, 2017
The Dangers of Copy and Paste in EHRs
The role of electronic health records (EHRs) as a contributing factor to malpractice claims has increased over the past three years—with copy and paste errors appearing in 14 percent of these claims. These cases from The Doctors Company’s EHR Closed Claims Study illustrate that danger.
Aug 28, 2017
The Search for Mary Smith
A case study illustrating the importance of researching healthcare technologies thoroughly before implementing them.
From
The Doctor’s Advocate
Dec 14, 2016
Perspectives on the Future of Medicine
From
The Doctor’s Advocate