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Top 10 Risk Management Recommendations

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TMLT risk management staff conduct on-site practice reviews to help physicians determine and address their medical liability risks. In 2016, risk managers reviewed more than 2,000 physician practices, and gave the following 10 recommendations most frequently.

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Top 10 Risk Management Recommendations

  1. 1. What every physician needs to know: top 10 risk management recommendations
  2. 2. about • TMLT risk management staff conduct on-site practice reviews to help physicians determine and address their medical liability risks. • In 2016, risk managers reviewed more than 2,000 physician practices, and gave the following 10 recommendations most frequently.
  3. 3. 1 document after- hours calls • Documenting after-hours calls and any instructions given to patients is important for continuity of care.
  4. 4. 2 EHR policies & procedures • The practice should maintain up-to-date, written policies for EHR processes. Policies may include privacy and security risk analysis, privacy and security training for staff, and other protocols to protect health information.
  5. 5. practice policies & procedures3• Keep a current policy and procedure manual for patient care. The manual should include information on communicating with patients, medication refills, order tracking systems, missed appointments, and emergency protocols.
  6. 6. 4 document names of others • It is important to note who is present during a patient visit because important instructions and education regarding the patient’s assessment and treatment are discussed.
  7. 7. edit pre- formatted text5• When using pre-formatted text or templates in EHRs, edit entries to ensure the record accurately reflects the clinical care delivered. Inconsistent or contradictory information in the record — due to default text or cloning of information from other visits — could lead to errors.
  8. 8. document follow- up requests • It is important for the continuity of care to document when a patient should return for a follow-up visit. This enables office staff to schedule the visit and may prevent the patient from falling through the cracks. 6
  9. 9. review and update medications • Prescription and over-the-counter medications should be reviewed and updated in the record at each visit to monitor compliance and help prevent adverse drug reactions. New patients should be encouraged to bring all current medications to the initial visit. 7
  10. 10. 8 have a tracking system in place • When patients are referred to specialists or to an outside source for lab or diagnostic tests, a tracking system can ensure the patient is seen and the results are received and reviewed.
  11. 11. document patient phone calls • Document patient phone calls and any instructions given to patients. As with the documentation of after- hours calls, this information can help the physician and subsequent caregivers in treating the patient. 9
  12. 12. document diagnostic reports • Documenting the physician’s review of consultant reports, diagnostic results, or outside tests demonstrates that the results were seen in a timely manner. When appropriate, document the action taken on specific results and the physician’s rationale for those actions. 10
  13. 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 Find us on:

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