___________________________________________________________________________ Risk Management
ESTABLISH AND USE EFFICIENT OFFICE PROCESSES
Despite the importance of complete medical records, surveys of office practices have shown that documentation is frequently incomplete or poor, with the most often lacking elements being [140]: • Updated problem list • Discussion of medications • Allergies • Informed consent process • Physician signature (to indicate review) Physicians should ensure that all essential information is documented in every patient’s record ( Table 6 ) [9; 85; 141; 142]. In addition, the record should include written instructions that were provided to the patient. Documentation should be clear, objective, specific, and dated. The use of abbreviations should be limited to those that are approved. Problems exist with both paper and electronic medical records. Paper records are often found to be illegible, and electronic medical records are frequently used inconsistently by the physicians within a practice [140]. Practices with electronic medical records should have a reliable backup system as well as a disaster recovery program [9]. A physician should never alter a medical record after a claim has been filed [9; 85].
Most medical errors have been found to be related to faulty systems rather than incompetence, which means that improving office and practice routines can help physicians avoid adverse outcomes [61]. Efficient office processes and procedures enhance the quality of patient care while decreasing the risk for medical error. Electronic health records are increasingly being used in hospitals and office-based practices. Since 2009, the percentage of clinicians and hospitals using electronic health records has almost doubled, from 46% in 2009 to 88% in 2019 [143]. Preliminary data suggest that physicians who use electronic health records are less likely to have paid malpractice claims [144]. However, the effect of electronic health records on the quality of care and the potential for mitigating malpractice is unclear. One study of electronic health record-related malpractice claims found that 48% of claims were caused either by system factors such as failure of drug or clinical decision support alerts, or by user factors, such as copying and pasting progress notes [145]. In addition, a 2018 survey of physician attitudes toward electronic health records showed that 69% felt that the clerical aspect of updating records takes
ESSENTIAL INFORMATION TO DOCUMENT
Full date (month, date, year) and time of the encounter Updated patient problem list Medication list (including over-the-counter drugs and supplements) Informed consents Thorough patient history (including experience with drugs or alcohol, and psychologic or social issues) Drug allergies and sensitivities Physician’s advice
Diagnosis (including thought process and list of possible diagnoses if uncertain) Physical examination findings (especially changes or absence of abnormality) Changes in the clinical course of a condition
All tests ordered or recommended All discussions with the patient All telephone conversations with the patient
All test results Follow-up plan Patient’s refusal of care or noncompliance with medications, treatment, or scheduled follow-up or appointments (and the physician’s efforts to educate the patient about the risks of noncompliance) Reports of consultations, with dates and times
Results of all testing, including the dates they were ordered, interpreted, and reviewed Notes regarding patient dissatisfaction and the response of the physician or other staff Source: [9; 85; 141; 142]
Table 6
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MDMI1826
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