Practice Management Book

Miscellaneous

  • Risk Management

http://www.fpnotebook.com/

Risk Management

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  1. Types of malpractice claims
    1. Negligent non-disclosure (informed consent)
    2. Negligence: Breach of standard of care
      1. Failure to diagnose (e.g. cardiac Chest Pain)
      2. Delay in diagnosis (e.g. Breast Cancer)
      3. Dropped ball
        1. Failure to follow-up on tests (labs, radiology)
        2. Failure to monitor
        3. Inadequate coverage while on vacation
  2. High risk areas
    1. Labor and delivery
    2. Medication reactions
    3. Pain management
    4. Sexual misconduct
    5. Inadequate supervision of mid-level practitioners
  3. General Rules
    1. Do not write what you wouldn't want the patient to read
    2. Protective measures
      1. Practice standard of care medicine
        1. Stay current
        2. Know local practices and protocols
        3. Refer or consult when appropriate
      2. Maintain good communication with patients, families
        1. Listen well
        2. Establish a relationship with patient and families
      3. Documentation
        1. See below
  4. Documentation (80% of cases are determined by this)
    1. Be accurate
    2. Be complete
    3. Be consistent
    4. Be objective
    5. Be legible
    6. Review canned phrases in electronic records
      1. Do not blindly insert text
    7. Never alter or edit prior records
    8. Avoid time delays in documentation
    9. Last Line of plan
      1. Assessment and Plan reviewed with patients
      2. Patients Questions answered
    10. Do not put non-relevant information in record
      1. Do not criticize in the medical record
      2. Do not speculate on cause of a complication
        1. Example: Perinatal asphyxia causing Cerebral Palsy
      3. Do not admit guilt or blame in the medical record
      4. Avoid non-neutral phrases in text (e.g. mistake)
      5. Do not document legal consultation in record

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