The document outlines the top 10 most frequent recommendations made by TMLT's Risk Managers during on-site practice reviews in 2017. These include: 1) updating medical records to ensure consistency and accuracy of information; 2) establishing policies for electronic health record security and documentation of review; 3) documenting diagnostic report review, patient instructions, and emergency protocols; and 4) properly recording injections administered and patient monitoring. The goal is to help physicians address medical liability risks through improving documentation practices.

1. WHAT EVERY PHYSICIAN
NEEDS TO KNOW:
RISK MANAGEMENT
TRENDS

2. ABOUT
TMLT’s Risk Managers
conduct on-site practice
reviews to help physicians
address their medical
liability risks.
The following slides summarize
the top 10 most frequent
recommendations made in 2017.

3. Update the medical record to reflect the patient’s current
condition and check for unintended system defaults to
normal or negative. The review of systems or exam should
not conflict with the history of present illness (HPI) or chief
complaint. Contradictory information in the record can
be a challenge in the defense of a claim or medical board
complaint.
CHECK EHR FOR UNINTENTIONAL
DEFAULT SETTINGS
1.

4. The practice should have written policies for electronic health record
security and processes, and policies should be kept current. Federal
privacy and security rules require that practices develop protocols
to protect the integrity and security of electronic protected health
information (ePHI). Policies should be signed by the physician(s) and
include implementation dates. Staff members should sign and date their
acknowledgement of policy review and understanding.
ESTABLISH EHR POLICIES
AND PROCEDURES
2.

5. DOCUMENT DIAGNOSTIC
REPORT REVIEW
Incoming consultant reports, diagnostic results, or outside
tests should include documentation of physician or provider
review. Timely review should be documented in the patient’s
record before scanning or filing. Documentation of the
physician’s review demonstrates that results were seen in a
timely manner. When appropriate, documentation regarding
actions or inactions on specific results and decision rationale
should be noted in the record.
3.

6. When using preformatted EHR text or templates, edit entries to ensure
the record accurately reflects the clinical care delivered. Inconsistent
information in the record, due to default text or the cloning of information
from one visit to the next, can be problematic in the event of a claim.
EDIT PREFORMATTED EHR
TEXT OR TEMPLATES
4.

7. Documentation of after-hours patient calls should be
evident in the medical record, including instructions given
to patients. This information can serve the physician and
subsequent caregivers in providing patient care. It is also
evidence of the instructions given to the patient in response
to specific medical complaints.
DOCUMENT AFTER-HOURS
CALLS
5.

8. Because instructions and education regarding the patient’s assessment
and treatment plan are discussed, it is important to note in the medical
record who is present during the visit, particularly when treating minors
or cognitively-impaired adults.
DOCUMENT NAMES OF PEOPLE
ACCOMPANYING THE PATIENT
6.

9. DOCUMENT PATIENT
RETURN VISIT
It is important, for the continuity of patient care, to
document in the medical record when the patient should
return for a follow-up visit. This enables office staff to
schedule the visit, preventing possible allegations of failure
to diagnose and treat.
7.

10. Having a written plan of action is recommended in the event of a patient
medical emergency in the office. Employees should be well versed in
these protocols, which may include access to emergency phone
numbers, patient assessment information, and how and where the
patient will be transported. Emergency equipment and medications
should be regularly maintained and inventoried.
ESTABLISH AN
EMERGENCY PROTOCOL
8.

11. The practice should have current policies and procedures in
place for patient care. Such policies include communication
with patients, medication refills, order tracking systems,
missed appointments, and emergency plans. Policies
and procedures should be signed by physicians and staff
members and include implementation and revision dates.
ESTABLISH PRACTICE POLICIES
AND PROCEDURES
9.

12. Information regarding injections administered in the office should
be documented in the medical record. Include dosage, lot number,
expiration date, route and location of injection, and the patient’s
condition post-injection.
Following an injection, patients should be observed for a minimum of
20-30 minutes, depending on the type of injection, for any reaction.
Documentation of the patient’s physical status should be recorded at
the time of discharge, such as “patient alert” or “no respiratory distress
noted.”
DOCUMENT INJECTIONS
10.

13. PROTECTION FOR A
NEW ERA OF MEDICINE
ABOUT TMLT:
With more than 20,000 health care professionals in its care, Texas Medical
Liability Trust (TMLT) provides malpractice insurance and related products
to physicians. Our purpose is to make a positive impact on the quality of
health care for patients by educating, protecting, and defending physicians.
www.tmlt.org
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