Medical Records and Documentation

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.

Professional Education
HIPAA Fundamentals: 2019-2020 Edition
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.
1.0 credits

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.

Professional Education
Advanced Practice Providers Closed Claims: What Can We Learn?
The Doctor's Advocate CME
A recent study by the Association of American Medical Colleges predicts that the U.S. would need an additional 95,900 doctors, 22,700 NPs, and 12,800 PAs immediately if healthcare use patterns were equalized across race, insurance coverage, and geographic location. More understanding of the liability associated with APPs can help provide insight on the current situation and identify strategies that decrease risk, improve patient safety, and advance patient care.
1.0 Credits

Professional Education
Dementia Q&A: What Physicians Ask About Diagnosis and Treatment
The Alzheimer's Project Series
This course focuses on the common concerns and questions expressed by physicians about dementia and cognitive impairment. This course covers making the initial observation of cognitive decline and beginning a conversation with older adult patients; overcoming common barriers to making a definitive diagnosis of dementia; and managing the ongoing clinical needs of patients experiencing dementia.
1.5 Credits

Professional Education
Alzheimer’s Disease and Related Dementias Evaluation and Diagnosis
The Alzheimer's Project Series
The second course introduces The Alzheimer's Project Evaluation Algorithm and Evaluation Instruments, and focuses on differential diagnoses. The course includes ideas for how to prepare and engage in a sensitive dementia diagnosis disclosure with patients and caregivers.
1.5 Credits

Professional Education
Dementia: Pharmacological Management of Behavioral and Psychological Symptoms
The Alzheimer's Project Series
This activity includes three video lectures and is the sixth in a series of courses that seek to educate clinicians on standardized screening, evaluation, and disease management of Alzheimer's and related dementias. This course focuses on the selection and appropriate usage of psychotropic prescription medications to manage the behavioral and psychological symptoms most frequently exhibited by patients with Alzheimer's and dementia diagnosis.
1.25 Credits

Professional Education
Dementia Screening Among Adults with Cognitive Decline
The Alzheimer's Project Series
The first course introduces The Alzheimer’s Project and highlights the increasingly important role of primary care practitioners in dementia care. It presents The Alzheimer’s Project Cognitive Impairment Screening Algorithm and Screening Instruments, and it addresses reversible conditions that may present similar symptoms to cognitive impairment. The course incorporates four videos, each followed by a series of related questions.
1.25 Credits

Professional Education
Physical Examination and Its Impact on Outcomes
The Doctor's Advocate
Advancements in technology improve the timeliness and accuracy of many diagnoses but the technology does not replace a thorough physical examination. For some diseases, such as Parkinson’s disease, herpes zoster, cellulitis, and Bell’s palsy the PE is the only diagnostic tool available. This short course makes the case for reversing the downward trend for physical examinations.
0.75 Credits

Professional Education
Neurological Case Study: Management of the Surgical Patient
Claims Corner CME
This Claims Corner examines a neurosurgical case that alleges several failures to assess and treat a patient in a timely manner. It also highlights the importance of communicating with physicians and advanced practice providers involved with post-surgical care.
0.5 Credits

Professional Education
Oral-Maxillofacial Surgery Informed Consent
Informed consent involves more than a patient signing a form. This activity explains how to enact an informed consent process based on best practices in dentistry and oral surgery.
1.0 Credit

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
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
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, Governor Emeritus, and Susan Shepard, MSN, RN, Senior Director, Patient Safety Staff 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.
2.25 Credits

Professional Education
Medical Office Assessments Reveal Hidden Liabilities
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 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
Shelley Rizzo, MSN, CPHRM, Patient Safety Risk Manager II
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
Distracted Practice Reduction: Strategies for Healthcare Leaders
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.
1.25 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
Pathology: Reducing Malpractice Claim Risks
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.
1.0 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 Governor Emeritus. Updated by 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.
1.25 Credit

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.
.75 Credit

Professional Education
The Alzheimer's Project
The goal of this 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 9.0 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.

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
Obstetrics: Preventing Adverse Outcomes
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. 
2.25 Credits

Professional Education
Gastroenterology: Preventing Adverse Outcomes
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
Cardiology: Preventing Adverse Outcomes
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
Patient-Physician 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.
1.25 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.

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
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.

Video May 06, 2017
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.

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
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.

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.

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.

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.

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 Governor Emeritus, Richard Cahill, JD, Vice President and Associate General Counsel, and Susan Shepard, MSN, RN, Senior Director, Patient Safety Staff 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 Governor Emeritus. Updated by Richard Cahill, JD, Vice President and Associate General Counsel, and Susan Shepard, MSN, RN, Senior Director, Patient Safety Staff 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.

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