Documentation/EHR/Patient Records

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, Part B News
‘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
Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company, Part of TDC Group
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
Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company, Part of TDC Group
Documenting a patient’s refusal of test or treatment options is key to minimizing risk exposure.

Jan 12, 2024
Interoperable Telehealth: Patient Safety Considerations
Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company
As efforts to connect patients and providers through telehealth continue, new delivery challenges have become apparent.

Dec 19, 2023
Telehealth: Frequently Asked Questions
Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company
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
Chad Anguilm, MBA, Vice President, In-Practice Technology Services, Medical Advantage
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
Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company, and Chad Anguilm, MBA, Vice President, In-Practice Technology Services, Medical Advantage
Remote patient monitoring technologies offer many benefits, but they also create potential malpractice risks.

Nov 30, 2023, MedCity News
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, Healthcare Risk Management
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.
0.5 credit

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, MDLinx
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?
Kathleen Stillwell, MPA/HSA, RN, Senior Patient Safety Risk Manager, The Doctors Company
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.
1.5 credits

May 01, 2023
Dealing With Online Patient Complaints
Richard Cahill, JD, Vice President and Associate General Counsel, and Kathleen Stillwell, MPA/HSA, RN, Senior Patient Safety Risk Manager, The Doctors Company
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
Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company
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
Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
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
Chad Anguilm, Vice President, In-Practice Technology, Medical Advantage; David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group, and Senior Vice President, Healthcare Risk Advisors; and Remi Stone, JD, Regional Director, Government Relations, The Doctors Company
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
David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors
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
Julie Brightwell, JD, RN, Director, Healthcare System Patient Safety, The Doctors Company
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.
0.5 credit

Sep 14, 2022
Recording Office Visits and Procedures: Pros and Cons for Healthcare Professionals
Richard F. Cahill, JD, 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.

Jul 28, 2022
Defensible Medical and Dental Records
Richard F. Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
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 missed or delayed diagnosis.
0.5 credit

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.

Apr 04, 2022
Strategies for Effective Patient-Assisted Telehealth Assessments
Sue Boisvert, BSN, MHSA, Senior Patient Safety Risk Manager, The Doctors Company
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.

Mar 01, 2022
Nine Tips for Telehealth Clinical Documentation
Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager, The Doctors Company
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 02, 2022
Informed Consent: Substance and Signature
Robert Morton, MAS, CPPS, Assistant Vice President, Department of Patient Safety and Risk Management, The Doctors Company
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.

Aug 30, 2021
Healthcare’s Digital Revolution: Are We Ready to Reimagine the Work?
David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors
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

Jul 21, 2021
Medical and Dental Record Retention
Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
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
Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
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
Chad Anguilm, MBA; Richard F. Cahill, JD; and Kathleen Stillwell, MPA/HSA, RN
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
Chad Anguilm, MBA; Richard F. Cahill, JD; and Kathleen Stillwell, MPA/HSA, RN
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
Chad Anguilm, MBA; Richard F. Cahill, JD; and Kathleen Stillwell, MPA/HSA, RN
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?
Chad Anguilm, MBA; Richard F. Cahill, JD; and Kathleen Stillwell, MPA/HSA, RN
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
Carol Murray, RHIA, CPHRM, Senior Patient Safety Risk Manager, and Richard Cahill, JD, Vice President and Associate General Counsel, The Doctors Company
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
Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company
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

Dec 23, 2020
Orthopedics Case Study: The Danger of EHR Templates
Robin L. Wessels, MBA, RN, Assistant Vice President, Department of Patient Safety and Risk Management, The Doctors Company
This example of an orthopedic claim involving accurate medical record documentation illustrates the importance of exercising caution when using EHR templates.

Nov 04, 2020
Smartphones, Texts, and HIPAA: Strategies to Protect Patient Privacy
Kim Hathaway, MSN, CPHRM, Patient Safety Healthcare Quality and Risk Management Consultant, The Doctors Company
The very convenience that makes using smartphone technologies so inviting may also create privacy and security violations.

Apr 29, 2020
The Faintest Ink: Documentation to Defend Quality Patient Care
Carol Murray, RHIA, CPHRM, Senior Patient Safety Risk Manager
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
Pamela Willis, BSN, JD, Patient Safety Risk Manager II
Shoulder dystocia claims have traditionally been among the most problematic to defend.

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
Darrell Ranum, JD, Vice President of Patient Safety and Risk Management
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.

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