Documentation/EHR/Patient Records Resources
Get risk management/patient safety resources and free accredited education on top issues surrounding documentation.
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Apr 18, 2025
Telehealth Clinical Documentation Strategies
The practice of telehealth creates additional and specific documentation requirements.
Apr 15, 2025
Obtaining Informed Consent in Clinical Teaching Situations
The basic principles governing informed consent and informed refusal apply to healthcare practitioners in all settings—including academic medical centers and any teaching location.
Apr 01, 2025
Avoid the Common Pitfalls in Medical Documentation
Daniel Kent Cassavar, MD, MBA, FACC, Medical Director, The Doctors Company and TDC Group, discusses the importance of accurate and thorough healthcare documentation.
Mar 07, 2025
EHR Interoperability and Artificial Intelligence: Don’t Put the Cart Before the Horse
Healthcare practitioners are ready to let AI lighten their loads—but first, we need to achieve EHR interoperability. AI can help us with that, too.
From
The Doctor’s Advocate
Feb 26, 2025
Are We Adopting AI Scribes Based on…Vibes?
This article examines AI-driven scribe technologies and their marketing claims. It also cites the article "Ambient Listening–Legal and Ethical Issues," in which I. Glenn Cohen, JD; Julie Ritzman, MBA, CPHRM; and Richard F. Cahill, JD, provide a comprehensive analysis of the legal and ethical considerations associated with the use of ambient listening technologies in healthcare settings.
Feb 19, 2025
Ambient Listening—Legal and Ethical Issues
Ambient listening, which involves using AI to record and analyze conversations between clinicians and patients, is one area of early AI adoption among healthcare professionals. I. Glenn Cohen, JD; Julie Ritzman, MBA, CPHRM; and Richard F. Cahill, JD, provide a comprehensive analysis of the legal and ethical considerations associated with the use of ambient listening technologies in healthcare settings.
Feb 12, 2025
Medical and Dental Record Retention
Retaining well-maintained patient records helps medical and dental professionals ensure continuity of care; protect against any future professional liability claims, licensing board complaints, and peer review inquiries; and can assist when responding to investigations by governmental compliance agencies and billing audits.
Dec 18, 2024
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.
Dec 17, 2024
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.
Nov 15, 2024
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.
Oct 09, 2024
Medical and Dental Records Guide
Our comprehensive guide offers actionable strategies to help you safeguard and manage patient records.
Sep 20, 2024
Recording Office Visits and Procedures: Pros and Cons for Healthcare Professionals
Proactively addressing the use of electronic recordings can help practitioners avoid misunderstandings, reputational damage, and potential liability.
Sep 09, 2024
Shoulder Dystocia Documentation: Implementing a Protocol
Shoulder dystocia claims have traditionally been among the most problematic to defend.
Aug 12, 2024
Your Patient Wants Records Sent Via Unsecure Email. Are You Covered?
Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company, part of TDC Group, provides recommendations for how to respond when patients request emailed medical records.
Aug 06, 2024
Informed Consent: Substance and Signature
True informed consent is a process of managing a patient’s expectations through shared decision making. It is not just a signature on a document.
Jun 18, 2024
Documentation Strategies for Open Notes in Healthcare: The Cures Act
Under federal law, patients have a right to access their health records. Our experts offer strategies to help you connect with patients.
Jun 18, 2024
Telehealth Visits: Strategies for Minimizing Patient Distraction
Patients who are distracted during telehealth visits can affect a practitioner’s ability to establish rapport and provide safe, effective treatment.
From
The Doctor’s Advocate
Apr 30, 2024
Mislabeled Diagnostic Specimens Put Lab Team at Risk: Patient Safety Impact Story
A clinical laboratory team that provides diagnostic evaluation of specimens sent in from multiple practices noticed an increase in tissue specimens arriving mislabeled, prompting a Practice Risk INSIGHT review by The Doctors Company.
Apr 29, 2024
‘Administrative’ Fees for Patient Messages? Not if It’s About Treatment
Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company, part of TDC Group, discusses the importance of documented policies and procedures surrounding non-medical services, like text communication, practices might charge for.
Mar 13, 2024
Manage Patient Distraction During Telehealth Visits
Distracted patient behaviors during telehealth visits can affect the practitioner’s ability to establish rapport and provide safe, effective patient care.
Mar 11, 2024
Informed Refusal
Documenting a patient’s refusal of test or treatment options is key to minimizing risk exposure.
Jan 12, 2024
Interoperable Telehealth: Patient Safety Considerations
As efforts to connect patients and providers through telehealth continue, new delivery challenges have become apparent.
Dec 19, 2023
Telehealth: Frequently Asked Questions
As the evolution of telehealth continues, we address questions asked by medical and dental practices.
Dec 07, 2023
ADA Accessibility for Healthcare Websites: How Practices Can Avoid Suits and Attract Patients
Healthcare practices and organizations 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.
Dec 05, 2023
Telehealth From the Field: Case Study Involving Remote Monitoring Problems
Remote patient monitoring technologies offer many benefits, but they also create potential malpractice risks.
Nov 30, 2023
Practice Risk Assessment: Do You Know What Your Patients Are Taking?
Richard F. Cahill, Esq., Vice President and Associate General Counsel, The Doctors Company, part of TDC Group, discusses how clinicians can promote positive outcomes and mitigate practice liability risks at a time when patients may be accessing care from myriad sources.
Nov 01, 2023
Be Prepared to Secure All Types of Evidence After Adverse Events
Richard F. Cahill, Esq., Vice President and Associate General Counsel, The Doctors Company, part of TDC Group, discusses the importance of healthcare providers preparing policies and procedures for securing evidence after adverse events.
Oct 26, 2023
Documentation Can Prevent Litigation: Patient Safety Impact Story
Our Patient Safety INSIGHT Services and extensive library of resources and tools take a data-driven approach to help you reduce adverse events while increasing patient safety and satisfaction. Here is one story of how our Patient Safety/Risk Management team reduced risk in a member practice.
Professional Education
Empowering Patients Through Open Clinical Notes
This course focuses on the 21st Century Cures Act mandate for interoperability to support patients’ access to their health information. To comply with the information blocking rule, healthcare providers must ensure that they are not engaging in practices that constitute information blocking, such as restricting access to patient electronic health information, imposing unreasonable fees for EHI access, or failing to respond to requests for EHI in a timely manner.
Sep 01, 2023
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.
Jul 07, 2023
An Indiana Healthcare Provider Mailed Test Results to the Wrong Patient: Is it malpractice?
Nichole M. Pieters, MS, RN, CEN, CPHQ, CPPS, Patient Safety Risk Manager, The Doctors Company, part of TDC Group, provides strategies to enhance patient privacy.
Jul 01, 2023
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.
Professional Education
Risk Management 101 for Healthcare Professionals: Malpractice, Patient Relations, and Documentation
This is an introductory level course about basic risk management for practicing clinicians focusing on malpractice, patient communication, and documentation. Healthcare professionals new to practice and more experienced will learn the legal elements of a malpractice claim that must be proven for a plaintiff to prevail. We share communication strategies to enhance patient understanding, compliance, and satisfaction while reducing the risk of abandonment when ending patient relationships. We address the importance of documentation, share open notes strategies for success, and strategies to demonstrate quality of care and reduce risk. Documentation examples are provided, as are tips for electronic health record (EHR) and telehealth documentation.
May 01, 2023
Dealing With Online Patient Complaints
Clinicians are understandably concerned about their reputations and the consequences of any negative comments posted about them on social media platforms.
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.
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.
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.
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 missed or delayed diagnosis.
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.
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 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.
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.
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.
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.