Medical Records and Documentation


Professional Education
Ob/Gyn: Telephone Communications (Claims Corner CME)
The most frequent inconsistent practice found in the Practice Risk INSIGHT assessments was telephone communication (22 percent not met). When appropriate and adequate systems are in place, the physician is less at risk for having a suit filed. This case-based study provides insights and risk management techniques to lessen the frequency and severity of such a claim.
0.5 credits

Professional Education
Psychiatry: Preventing Adverse Outcomes
The Doctors Company study of closed claims reveals areas of higher risk in outpatient psychiatry practices. Using this as a foundation, the course provides information to evaluate your practice and make changes to improve decisions about treatment, operational processes, reporting, and documentation.
1.5 Credits

Professional Education
Preventing Adverse Outcomes When Treating Children (The Doctor's Advocate CME)
The Doctors Company studied claims filed on behalf of pediatric patients that closed over a 10-year period from 2008 through 2017. You are provided the most common types of claims and includes expert insights into the specific elements that led to patient injury, and risk mitigation strategies.
1.0 Credit

Feb 08, 2019
EHR Risks Report: How to Protect Your Practice
The integration of the electronic health records (EHR) into medical practices has brought new liability risks. This guide includes an analysis of EHR-related malpractice claims and practical tips to mitigate EHR risks.

Feb 08, 2019
Cybersecurity and Data Breaches Report
It’s not a matter of if a data breach will occur in your medical practice—it’s a matter of when. Make sure your practice is prepared with this guide, which covers how to comply with HIPAA rules in the event of a breach, how to thwart ransomware attacks, how to combat password theft, and more.

Feb 01, 2019
MACRA 2019 Changes Address Physician Concerns
By Kim Hathaway, MSN, CPHRM, Healthcare Quality Patient Safety and Risk Consultant
Centers for Medicare & Medicaid Services (CMS) is taking steps to ease regulatory burdens by removing process measures, developing more outcome measures, changing the fee schedule to support telemedicine technology, and focusing on EHR interoperability. The changes were effective on January 1, 2019.

Jan 28, 2019
Smile! The Doctor Is on Camera: The Pros and Cons of Recording Office Visits and Procedures
Rich Cahill, Vice President and Associate General Counsel
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.

Dec 28, 2018
Curbside Consultations: Patient Safety and Legal Risks
Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management 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.

Dec 20, 2018
Reduce Risks in Patient Handoffs: Signing Off and Signing Out
Ann S. Lofsky, MD (1956–2008), Governor Emeritus, and Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management 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.

Professional Education
Medicare Fraud and Abuse: Prevention, Detection, and Reporting
Created by the Centers for Medicare and Medicaid Services (CMS), this activity is designed for all Medicare providers. You will learn what CMS defines as fraud and abuse, how the government fights it, and how to report it.
1.25 Credits

Professional Education
Risky Practices: Hidden Liabilities Identified by Medical Office Assessments (The Doctor's Advocate CME)
The Doctors Company’s patient safety risk managers conducted office practice assessments across a range of practice environments around the country. This activity analyzes the results, highlights problem-prone areas, and offers strategies to minimize areas where patients can “fall through the cracks” and leave the practice vulnerable to a malpractice claim.
1.0 Credit

Aug 14, 2018
Surprise, Disappointment, and Anger Lead to Malpractice Lawsuits
Mark Gorney, MD, FACS (1924–2014), Governor Emeritus, and Richard Cahill, JD, Vice President and Associate General Counsel
The common denominator of all malpractice claims is a combination of surprise, disappointment, and anger. Anger is by far the most common factor in stimulating further action by the patient. Regardless of the actual cause, anger will be focused on the most convenient and visible target—the physician.

Jul 30, 2018
Cybersecurity Insurance for Medical Practices—The Basics
David J. Eismont, ARM, Senior Director of Business Development
More medical practices are purchasing an insurance policy to cover the substantial costs of a data breach. Here is an overview of what your practice can expect from a cybersecurity policy.

Jul 27, 2018
Distracting Devices in Healthcare: Malpractice Implications
Digital distraction in healthcare is emerging as a great threat to patient safety and physician well-being. Personal electronic devices can create a digital distraction so engaging that it consumes awareness, potentially preventing healthcare providers from focusing on the primary task at hand—caring for and interacting with patients.

Video Jul 27, 2018
Malpractice Repercussions: Distracting Devices and Patient-Centered Care
The health environment has been invaded by not only medical technology, but by individuals who become too connected to their own devices. Steven Weintraub, MD, interviews Peter J. Papadakos, MD, FCCM, FAARC, about distracting devices in the context of patient-centered care and the malpractice repercussions that occur when practitioners appear to be distracted.

Video Jul 27, 2018
The Stress Paradigm: Distracting Devices and Patient-Centered Care
The health environment has been invaded by not only medical technology, but by individuals who become too connected to their own devices. Steven Weintraub, MD, interviews Peter J. Papadakos, MD, FCCM, FAARC, on distracting devices and how they contribute to physician stress.

Professional Education
How Healthcare Leaders Can Reduce Risks of Distracted Practice in Their Organization
Healthcare leaders play an important role in patient safety. This activity examines how distraction and interruptions impact safe patient care and identifies what leaders of organizations, teams, and departments can do to address the problem.
1.0 Credit

Professional Education
Prevention of Medical Errors (Florida Practices)
This activity is specific to Florida statutes and reflects regulations effective February 2018. It delves into the prevention of common performance and diagnostic errors including adverse drug events, wrong-patient/wrong-site/wrong-procedure, unintended retention of foreign objects, surgery complications, and sepsis. It also covers conditions related to respiratory, ob/gyn, cardiology, and cancer.
2.0 Credits

Jun 06, 2018
Is It Safe to Store PHI on Remote Cloud Servers?
David McHale, Senior Vice President and Chief Legal Counsel
Cloud storage is a convenient and cost-effective solution for medical practices and facilities, but precautions must be taken to ensure stored patient data (PHI) is secure. This article has tips for choosing a cloud service provider.

Professional Education
Reducing Risk of a Pathology Malpractice Claim
By recognizing the risks associated with their specialty, pathologists can bring about changes that result in faster, higher-quality, and safer care. This course requires reading six pathology-related articles published by The Doctors Company, answering a series of questions, and reflecting on changes that could reduce risks and improve care in your practice setting.
2.0 Credits

Apr 23, 2018
Physician Beats Burnout and Restores Quality of Life—with Scribes
Hans Haydon, MD, an internal medicine physician, was distressed that time-consuming EHR documentation was driving up his work hours and stress. With the use of a medical scribe, Dr. Haydon was able to restore productivity, quality interactions with patients, and work-life balance.

Mar 29, 2018
Obtaining Informed Consent in Teaching Institutions
Mark Gorney, MD, FACS (1924–2014), Governor Emeritus, and Richard Cahill, JD, Vice President and Associate General Counsel
It is important to inform patients when a resident physician will perform all or part of a procedure.

Professional Education
Taking the Mal Out of Malpractice: Incident Analysis Leads to Sustained Improvement
Improvements made in clinical care often result by looking beyond what seems to be the obvious cause to find the underlying or root of an actual or potential injury. This activity demonstrates how changes designed to tackle root cause(s) are more likely to produce sustainable improvements in your practice that prevent reoccurrence of an injury, error, or near miss.
1.0 Credit

Feb 23, 2018
EHRs Can Advance Good Medicine―If Doctors Are Aware of the Risks
David B. Troxel, MD, Medical Director
Nearly all hospitals and 80 percent of medical practices use electronic health records, presumably to help improve access to health information and increase productivity. The problem is that none of these digital tools were designed specifically to advance the practice of good medicine.

Professional Education
Spinal Epidural Abscess: A Case Study Review
Designed primarily for hospitalists and other physicians practicing in the hospital setting, this activity explores the problems associated with diagnosing and treating spinal epidural abscess. It defines the most frequent type of risk and the severity of losses, as well as strategies to overcome these risks.
1.0 Credit

Professional Education
The Alzheimer's Project
The goal of this five-part series is to educate clinicians on standardized screening, evaluation, and management of Alzheimer’s disease and related dementias. The Doctors Company is pleased to support Champions for Health in training primary care physicians and other healthcare practitioners to diagnose and care for patients with Alzheimer’s or dementia.
Up to 7.5 Credits

Video Jan 04, 2018
Disaster Preparedness for Your Medical Practice
Recent fires, hurricanes, and floods nationwide have highlighted the importance of planning for disasters. Wildfires in California forced several physicians to quickly relocate their practices―some permanently―and to move scheduled procedures to different facilities. Hurricane and flood damage in Texas and Florida left practices without power for days or even weeks. Is your practice prepared for this type of situation?

Dec 13, 2017
Disaster Preparedness for Your Medical Practice
Julie Brightwell, JD, RN, Director, Healthcare System Patient Safety, Department of Patient Safety and Risk Management
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

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.

Professional Education
Preventing Adverse Outcomes: Obstetrics
This activity is based on The Doctors Company's guide to reducing patient safety risks in obstetrics and gynecology. It is intended to provide essential training for obstetricians, gynecologists, family practitioners, and advanced practice providers who are actively involved in delivering women’s healthcare. 
3.0 Credits

Professional Education
Understanding Malpractice Claims and Legal Proceedings
This activity is an introduction to the four essential elements necessary for filing a malpractice claim. It reviews common allegations, defines steps in the legal process, explains legal terms, and discusses the process of arbitration.
1.0 Credit

Professional Education
Telemedicine: New Tools, Emerging Risks
Awareness of the emerging risks associated with telemedicine is important as more and more practices use technology to care for patients. This activity outlines risks related to regulatory restrictions, privacy and security, inaccuracies in patient self-reporting, and symptoms that may only be detected in person. It also suggests ways to reduce risks and challenges when using telemedicine.
1.25 Credits

Professional Education
Preventing Adverse Outcomes: Gastroenterology
This activity identifies the factors that contribute to patient allegations and injuries as revealed by closed claims involving gastroenterologists. It provides physicians with appropriate strategies for their practice that, if implemented, can improve quality and safety and positively affect patient outcomes.
1.0 Credit

Professional Education
Preventing Adverse Outcomes: Cardiology
This activity shares insights from an analysis of closed claims involving cardiology. It identifies the most common risks and the system and process improvements that enhance patient safety and mitigate factors that can lead to adverse events and lawsuits.
1.0 Credit

Professional Education
Physician-Patient Relationship: When Does It Begin and When Does It End?
This activity increases understanding of the principles that form a physician-patient relationship and the necessary considerations before terminating a relationship. It also highlights the importance of timely documentation when establishing or ending a physician-patient relationship.
1.0 Credit

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.

Oct 16, 2017
Electronic Health Record Closed Claims Study: Navigating the Rising Risks of EHRs
The number of malpractice closed claims in which EHRs were a contributing factor has increased continuously over the past 10 years. While EHRs have brought many positives, they have also created new risks and frustrations for doctors and patients.

Aug 15, 2017
Objective Review of Potential Risks in a Medical Practice Can Be Beneficial
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
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 medical scribes.

Mar 19, 2017
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).

Video Feb 07, 2017
Paying Cyber Ransom: Pros and Cons
If ransomware strikes a healthcare organization, the cybercriminals behind the attack will demand a payment in exchange for restored access to the organization’s data. Typically the demand is for bitcoin equivalent to less than $10,000. Paying the ransom may be an attractive option if a healthcare organization’s entire network has been compromised and no reliable backup exists. However, there are several compelling arguments against paying.

Video Feb 07, 2017
3 Steps for Ransomware Defense
While no environment is completely secure from cyberattack, a healthcare organization can take steps to reduce the likelihood that it will suffer the consequences of ransomware.

Video Feb 07, 2017
Why Cybercriminals Prefer Bitcoin
Currency is a means of exchange typically sanctioned by a central body like a government or central bank. Bitcoin, however, is a decentralized digital currency based on a public ledger secured by cryptography. As a result, bitcoin transactions are largely irreversible and untraceable. This makes bitcoin and other digital currencies attractive to cybercriminals. They give cybercriminals a means of monetizing their attacks anonymously—one reason that ransomware attacks have proliferated.

Video Feb 07, 2017
Ransomware: Do's and Don'ts
Panic is the typical reaction when a healthcare organization suffers a ransomware attack. If an organization lacks a thought-out response plan for this type of crisis, people tend to overreact. They may do things that will make it harder to recover from the attack and could increase future liability. But an organization can avoid panic by having an incident response plan in place. This plan should provide a framework of actionable steps, including what to do, who is going to do it, and what is going to happen as a result.

Video Feb 07, 2017
Patient Data Trafficked on the Dark Web
Cyberattacks in the healthcare industry have proliferated for two main reasons. One, cybercriminals can sell PHI at a high price on the dark web (the online market where stolen data is bought and sold). Two, healthcare organizations are vulnerable to cyberattacks because they lack the defenses of banks and other financial institutions. Particularly attractive to cybercriminals are midsized healthcare organizations, which in general are underprepared to counter this threat.

Video Feb 07, 2017
Ransomware Threatens Patient Care
Cybercriminals typically target healthcare organizations using malicious software, or malware. Most malware is programmed to steal data and take it outside of the network. But cybercriminals today are often choosing a different form of attack: ransomware. A ransomware attack uses encryption to prevent the healthcare organization from accessing its PHI. This puts the healthcare organization in a serious crisis, as PHI is critical to providing care to patients.

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

Video Jul 14, 2016
A New Vital Sign: Health Data
A whole new generation of vital signs: That’s how a busy emergency physician wants to see data transform healthcare. Learn how these new vital signs will guide care, bringing personalized medicine to each patient—it’s the vision of Kevin R. Ward, MD, executive director of Fast Forward Medical Innovation: University of Michigan Medical School, a panelist at The Doctors Company’s 2016 Executive Advisory Board.

Video Jul 14, 2016
Leveraging Data to Improve Patient Care
Right care, right patient, right time, right place. For that to happen, doctors need data immediately available to them, says Kevin R. Ward, MD, executive director of Fast Forward Medical Innovation: University of Michigan Medical School , a panelist at The Doctors Company’s 2016 Executive Advisory Board.

Video Jul 14, 2016
Data Overload: Doctors, Apps, and Wearables
More and more patients are using mobile healthcare apps and wearables, giving them the ability to monitor their own health signs, like activity levels and blood sugars. But for doctors, collecting 24/7 data from their hundreds of patients is overwhelming and currently not doable. What tools or systems do we need to put in place to address this digital health data overload? Robert M. Wachter, MD, explains two possible solutions in this video from The Doctors Company’s 2016 Executive Advisory Board.

Video Jul 14, 2016
3 Steps to Build Better EHRs
When we transitioned from a paper-based medical system to a digital medical system, we didn’t understand the importance of usability. As a result, EHRs are often clunky, not intuitive for doctors and nurses, and raise patient safety concerns with an overwhelming amount of alerts and alarms. Getting these systems into a user-focused design requires three main steps—hear from Robert M. Wachter, MD, in this video from The Doctors Company’s 2016 Executive Advisory Board.

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.

Video May 06, 2016
Seven Tips to Help Stop Ransomware
Preparation is key: Once you've been hit by ransomware and your hard drives encrypted, your options are incredibly limited. This video shares the top seven tips you need to know to help your medical practice or hospital prevent or recover from a ransomware attack.

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.

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 (1924–2014), Governor Emeritus, Richard Cahill, JD, Vice President and Associate General Counsel, and Susan Shepard, MSN, RN, Senior 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.

Video May 26, 2015
Analysis of EHR-Related Claims: Part I
User factors, such as incorrect information in the EHR from data entry errors, prepopulating and copying and pasting data, and conversion from paper to digital files, contributed to 64 percent of EHR-related claims. System factors, including system failures, insufficient scope or lack of area for documentation, and outdated templates, contributed to 42 percent of the claims. The most common patient allegation, occurring in 27 percent of these claims, was diagnosis-related error.

Video May 26, 2015
Analysis of EHR-Related Claims: Part II
The second video of a two-part series examining EHR-related malpractice claims explores several claims brought about by both user and system factors, including copy-and-paste errors, insufficient area for documentation, and lack of an EHR drug alert.

Apr 06, 2015
Accurate Medical Records: Your Primary Line of Defense
Mark Gorney, MD, FACS (1924–2014), Governor Emeritus; Richard Cahill, JD, Vice President and Associate General Counsel; and Susan Shepard, MSN, RN, Senior Director, Patient Safety and Risk Management 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.

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.

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.

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