Tip #1: Maintaining Patient Confidentiality
Tip #2: Tracking Test Results
Tip #3: Prescription medications and patient safety
Tip #4: Failure or malfunction of office equipment can lead to patient,
staff or provider injury
Tip #5: Following up missed or cancelled appointments.
Tip #6: Managing medication samples
Tip #7: Safely caring for obese patients in the office practice
Tip #8: Management and documentation of after-hours telephone calls from
Tip #9: Reliably Communicating and Acting on Critical Test Results.
Tip #10: Managing Chronic Pain Patients.
Tip #11: Using chaperones during physical examinations.
Tip #12: Promoting communication between the referring and the consulting physicians.
Tip #1: Maintaining Patient Confidentiality (PDF)
Inadvertent breach of patient confidentiality.
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Office staff must be aware that routine office practices, such as discussing patient
information within earshot of other patients, can breach patient
1. Educate your staff periodically to reinforce the need to maintain patient confidentiality
and to never never discuss patients outside the office.
2. Every year, have your staff sign a confidentiality agreement.
3. Assess your physical premises to determine the flow of patients through the office and how
best to ensure that confidential patient information, written or spoken, is kept private.
4. Assess staff work areas to determine patients' accessibility to computer screens and patient
information. How quickly are computer users logged off the system when data entry stops?
5. Set up your office in such a way that staff conversations can not be overheard in the waiting area.
6. Obtain written consent from patients so that minimal information can be left on telephone
Tip #2: Tracking Test Results (PDF)
Tests may not have been completed or results may be lost, overlooked, or not
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Follow-up procedures are important to ensure that patients receive the necessary testing,
as ordered, and that results are returned to the office and properly reviewed.
1. Educate patients about the need for the testing, and document this conversation.
2. Implement a follow-up system in your practice to ensure that patients have undergone
the recommended testing and that the results are returned to the office.
3. The follow-up system should include the patient's name, the date the test was ordered,
when the results were received, and when the patient was notified.
4. The physician should review, initial, and date the reports before they are filed in the
5. Attempts should be made to contact patients who have not undergone the recommended testing.
These attempts should be documented in the medical record and, once the patient has been
reached, he/she should again be urged to obtain the requested testing.
6. Include a process in your follow-up system to verify that consultations were obtained.
Tip #3: Prescription medications and patient safety (PDF)
Patient injuries and malpractice claims can result from known risks and side
effects, allergic reactions, drug interactions or errors in prescribing.
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1. Since there are significant risks and side effects associated with prescribed drugs,
physicians must discuss this information with their patients and document these discussions
in the medical record.
2. The patient's allergic history must be reviewed
before a new drug is prescribed. Known
allergies must be documented and flagged in a prominent, easily viewable place in the medical record.
3. Medication updates, including dosage changes and refills, and the use of any over-the-counter
drugs, must be clearly documented in the medical record. A medication flow sheet can be used
to monitor and track current and past medication usage, as well as allergies.
4. Any specific instructions provided to patients regarding the medications must also be
written in the record.
5. There must be written confirmation that the laboratory and/or diagnostic tests necessary
to monitor certain drugs for their effectiveness or side effects are ordered, as recommended
by professional guidelines, and the test results viewed and necessary adjustments made.
6. The rationale for the discontinuing a medication must be documented in the medical record.
Tip #4: Failure or malfunction of office equipment can lead to
patient, staff or provider injury (PDF)
More procedures are being performed in the office practice setting than ever before
and more physicians own or lease office equipment. Failure or malfunction of office
equipment can lead to patient, staff or provider injury. Therefore, providing for the
safety of patient, staff and providers by performing necessary inspections and maintenance
of equipment is an important part of office practices today.
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1. Written policies and procedures must be developed to define the use and maintenance
of office equipment. The manufacturers' directions for use and their recommended schedules
for preventative maintenance must be followed.
2. A written log of all maintenance activities must be maintained and retained.
3. A specific staff member must be designated to be responsible to confirm that all required
inspections and maintenance of equipment have been performed at the proper intervals.
4. All patient care equipment must be inspected on an annual basis at a minimum, or more
often if recommended by the manufacturer
5. All patient care equipment must be tagged to reflect the inspection date, the initials of
the inspector, and the date the next inspection is due.
6. All staff must be properly trained in the use of all
equipment. Documentation of training and education must be maintained in their personnel files.
7. Equipment must only be used by an employee if it is within the applicable scope of
practice for that employee. This includes licensed professionals. This must be determined
prior to the employee being trained and/or using the equipment.
8. Every piece of equipment that malfunctions must immediately
be removed from service, and labeled as defective. The written office policy must contain a
provision to sequester any piece of equipment which may be directly involved in injury to a patient,
staff, or provider. Prompt notification to MLMIC is recommended when an equipment-related injury occurs.
Tip #5: Following up missed or cancelled appointments. (PDF)
A missed or cancelled appointment, and the failure of a practice to follow up with
or contact the patient, may result in a serious delay in diagnosis or treatment
and a subsequent risk of liability for the provider.
1. Develop policies and procedures in your practice for following up with patients
who have missed or cancelled appointments.
2. Physicians should be made aware of all missed or cancelled appointments. The staff
should inform the physician(s) of these patients at the end of the day and have the medical
records ready for the physician's review.
3. The physician should assess the clinical importance of the appointment, the severity
of the patient's medical condition, and the risk(s) associated with the missed or cancelled appointment.
4. A reminder telephone call from the office staff may suffice for patients at minimal
risk. The time and date of the telephone call and the content of the message or conversation
must be documented in the patient's record.
5. A telephone call from the physician may be indicated for patients at higher risk. The
physician should emphasize the importance of follow-up care and the risks inherent in failing
to obtain it. This telephone conversation must also be documented in the medical record.
6. If there is no response from the patient or the patient develops a pattern of not keeping
or missing appointments, a certified letter, with a return receipt requested, should be mailed
to the patient to advise him/her of the risk of non-compliance. A copy of the letter and the
signed receipt must be maintained in the patient's chart.
7. All efforts to contact the patient, either by telephone or letter, must be documented in
the medical record. This provides written evidence that the patient was clearly made aware of
the importance of continuing medical care.
8. Educate your staff about patient follow-up policies and procedures in your practice. Conduct
periodic record reviews to determine staff compliance and to evaluate the effectiveness of the
processes you have implemented.
9. Continued failure of patients to keep appointments may be deemed non-compliance with treatment.
Consideration should be given to discharging the patient from your practice since patient non-compliance
may increase a physician's risk of liability. The attorneys at Fager & Amsler, LLP are available to
assist you to determine how and when to properly discontinue a physician-patient relationship due
to patient non-compliance.
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Tip #6: Managing medication samples (PDF)
Medication samples are widely used in physicians' offices. The proper storage,
handling, dispensing, and disposal of medication samples are necessary to prevent
medication errors and subsequent patient injuries.
1. Develop policies and procedures for storing, handling, dispensing, and disposing of
medication samples in your office practice.
2. Store medication samples in a safe and secure location in your office to reduce the risk
of theft and unauthorized use. Limit access to licensed staff members. Medication samples must
not be kept in examination rooms or areas that are easily accessible to patients and visitors
(e.g., in unlocked drawers or on countertops). Follow the manufacturer's recommendations for
storage of each drug.
3. Maintain a log of your supply of medication samples. Assign the responsibility of monitoring
and tracking the inventory to one staff member. The log should include documentation of the
monitoring of expiration dates.
4. Explain the proper use of the drugs to the patients and any special instructions or warnings
in the event the patient does not have sufficient reading skills.
5. Record all medication samples dispensed to patients in the medical record. Documentation
should include the medication, the amount, the dosage, the frequency, and any instructions
provided to the patient.
6. Properly dispose of expired medication samples, when necessary, in accordance with state,
federal, and local laws.
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Tip #7: Safely caring for obese patients in the office practice
Obesity is a serious health issue of epic proportion in the United States. Physicians' offices
may not be well equipped to accommodate obese patients. Injuries can occur if appropriate
equipment is not available to care for these patients. Further, bias or ambivalence by the
healthcare team in treating obese patients can negatively affect patient care and lead to
Providing a safe environment while optimizing sensitivity to the needs of the obese patient
will enhance patient care and minimize your exposure to claims of negligence.
1. Examination rooms and waiting areas should contain appropriate and safe furnishings, such
as large sturdy chairs, high sofas, benches, or loveseats that can accommodate obese patients.
2. Diagnostic and interventional equipment that can accommodate morbidly obese patients should
be available, if regularly needed. This may include, but is not limited to:
- Appropriate scales for patients who weigh more than 350 lbs.
- Extra large adult-size blood pressure cuffs
- Gowns to accommodate patients weighing more than 350 lbs.
- Extra-long phlebotomy needles and tourniquets
- Large examination tables
- Toilets that can accommodate patients who weigh more than 300 lbs.
- Sturdy grab bars in bathrooms
- Sturdy step stools in examination rooms
3. The staff must be knowledgeable about the weight limits of their office equipment. Color coded labels can be used
to discreetly identify weight limits. Further, the office staff must be educated and trained in the use of safe
techniques for lifting and transferring obese patients.
4. While there are many medical complications of obesity, these patients are less likely to obtain preventative
care and more likely to postpone or cancel appointments because of embarrassment and/or a feeling of bias on the
part of healthcare providers due to their weight. Patient support and follow-up are important.
5. Healthcare providers must address their own potential for weight bias.
Recognize your pre-conceived ideas and attitudes regarding weight. Learn how to give appropriate feedback to patients
to encourage healthful changes in behavior. Encourage patients to actively participate in their plan of care and set goals.
6. Educate the staff about the needs of this patient population to enhance their ability to demonstrate understanding,
respect, and sensitivity to these patients.
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Tip #8: Management and documentation of after-hours telephone
calls from patients. (PDF)
The failure to properly handle and document after-hours telephone calls can
adversely affect patient care and lead to potential liability exposure for the
physician. Further, should a telephone conversation become an issue in a lawsuit,
and it is not documented, the jury is less likely to believe the recollection
of the physician, who receives a large number of calls on a daily basis.
1. Establish a system to respond to after-hours telephone calls. This system should
include a consistent process to help ensure that all after-hours calls are responded to
in a reasonable time frame and are documented in the patient's medical record.
2. Medical record documentation of after-hours calls should include the following:
- Patient’s name
- Name of the caller, if different than the patient, and the individual’s
relationship to the patient
- Date and time of the call
- Reason or nature of the call, including a description of the patient’s
symptoms or complaint
- Medical advice or information that was provided, including any medications
that are prescribed.
3. If the patient's condition warrants the prescription of medications, it is important
to inquire about and document any medication allergies, as well any other medications the
patient may be taking.
4. When providing after-hours coverage for another physician's practice, a process should
be in place to ensure that documented telephone conversations are promptly forwarded to that
5. If you use an answering service, it should be periodically evaluated for courtesy,
efficiency, accuracy, and proper recordkeeping.
6. The use of answering machines for after-hours calls is not recommended for the following reasons:
- There are no safeguards in the event of an answering machine malfunction.
- Patients do not always understand that no one will call back, even if this
is stated in the message, due to limited English capacity, anxiety, or other
- If, as a last resort, an answering machine must be used, the message must be
brief and simple: "The office is now closed. Please go to the emergency
department if you believe this is an emergency."
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Tip #9: Reliably Communicating and Acting on Critical Test Results.
According to a study in the June 22, 2009 issue of Archives of Internal Medicine,
7%, or about 1 out of 14, clinically significant abnormal test results were not
reported to the patient or documented as disclosed to the patient by their primary
care physician. Abnormal test results requiring follow-up that are not reviewed or
communicated to the patient can result in missed/delayed diagnoses, patient injuries,
and subsequent malpractice claims. If a physician ordered a test, he or she is responsible
to act upon the results of that test. Both the physician's office and the hospital
must have appropriate policies and procedures in place to confirm that test results
are reviewed, communicated, and acted upon.
1. Tests which are ordered must always be documented in the patient's medical record. In the office setting, a stamp or check-off sheet may be used to document orders for routine or recurrent laboratory and other tests, such as PSAs, mammograms, INRs, etc.
2. A log book must be maintained to confirm and document receipt of the test results, including: the date, the patient's name, and the test ordered. The staff must review the log at least weekly, and highlight and date receipt of those results. If the office practice has an electronic health record system, a number of software programs are available that can track the status of diagnostic and laboratory test results. A plan for follow-up of outstanding results must be developed and made part of the office's procedures.
3. The physician must date and initial all incoming laboratory reports and diagnostic tests to confirm review of the results.
4. The physician must also document communication of the test results to the patient or referring physician in the medical record. The note must state that the patient and/or the physician have been advised of the results. The recommended action(s) to be taken, if appropriate, must also be documented. The results of tests and actions to be taken must also be discussed during subsequent visits and those discussions documented in the patient's medical record.
5. Laboratory or other diagnostic tests ordered for a hospital in-patient also require follow up, particularly when the results are received after the patient's discharge. A mechanism must be in place at the facility to communicate and confirm that the test results have been sent to the patient's primary care provider or other responsible provider, if the patient is no longer an in-patient. It is important for physicians to clearly establish who is responsible for follow-up, when tests are ordered for a patient by another specialist or consultant.
6. In the ED, there must be a system in place to confirm that test results are reviewed prior to the patient's discharge. It is very important to document that the results received after discharge, together with recommended action (e.g. to return to the ED) are communicated to the patient and their primary care or responsible provider. The individual who is responsible for communicating with the patient after discharge must be determined prior to discharge.
7. In the hospital, the progress notes must contain documentation that the laboratory or other test result has been reviewed and what action has been taken due to the result.
8. The American College of Radiology advises that a radiologist must communicate "non-routine findings" in a manner most likely to reach the attention of the treating or referring physician. This must be done in sufficient time to provide the most benefit to the patient. Communication by telephone or in person to the treating or referring physician or his/her representative is appropriate. However, receipt of the findings by the ordering physician must be documented in a log or in the EMR. Results may be communicated directly by the radiologist or, when judged appropriate, by the radiologist's designee.
9. The patient and family (when permitted by the patient) must be included as partners in care. By doing so, the patient is much less likely to forget that he/she is awaiting a test result. Patients must be advised not to assume that no communication means a normal test result. There should be a fail-safe mechanism for patients to obtain all test results.
10. Policies and procedures, as well as patient records, must be retrospectively reviewed on a regular basis to confirm that patients are being informed of test results and that this type of communication is being documented. An ongoing system for such retrospective review should be developed and corrective action implemented to further reduce errors in the future.
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Tip #10: Managing Chronic Pain Patients
The management of chronic pain, through the prescription of medication, poses challenges
and risks to both the patient and the healthcare provider (physician, physician assistant,
or nurse practitioner). These risks include the potential for patient addiction, diversion,
the possibility of overdose, and death, whether accidental or the result of suicide.
The provider's fear of the following risks may lead to inadequate treatment of the patient:
- liability for failure to adequately treat pain;
- liability for allegedly inappropriately prescribing controlled substances;
- potential for civil charges being brought against a physician or other provider for
the patient's diversion of narcotics and/or drug abuse or overdose; and
- liability for failing to recognize a patient's addiction and/or diversion and to refer
the patient for treatment
1. Perform and document a thorough initial evaluation of the patient. This should include: a history and assessment of the impact of the pain on the patient; the nature, type and causation of the pain; and, a focused physical examination to determine if there are objective signs and symptoms of pain. The provider must also review pertinent diagnostic studies and previous interventions, a drug history, and assess the extent of co-existing medical conditions which impact the patient's pain. It is important to obtain the names of all other providers the patient is seeing or has seen, and the pharmacies the patient uses.
2. Develop a specific treatment plan based upon the evaluation.
3. Maintain accurate, legible, and complete medical records which clearly support the rationale for the proposed treatment plan.
4. Perform a thorough informed consent discussion regarding the plan of care, including the risks, benefits, and alternatives, and the risks of the alternatives, including no treatment with controlled substances.
5. Request the patient's consent to obtain copies of the records of all prior treating physicians, and review these records before prescribing narcotics, to determine if there is a history of drug seeking behavior or abuse.
6. Use a written pain management agreement when prescribing controlled substances for patients with chronic pain. If the patient has a prior history of drug abuse, refer the patient to a pain management practice or clinic, if possible. A pain management agreement outlines the expectations of the provider and the responsibilities of the patient, including:
- baseline screening of urine/serum medication levels
- periodic unannounced urine/ serum toxicology screening
- medications to be used, including dosage(s) and frequency of refills
- a requirement that the patient receive medications from only one physician and
use only one pharmacy
- frequency of office visits
- reasons for discontinuance of drug therapy (e.g. violation of agreement)
A sample pain management agreement can be obtained by contacting Fager and Amsler, LLP at (877) 426-9555
7. Document and monitor all prescriptions and prescription refills.
8. Protect prescription blanks. Limit and monitor staff access to computer-generated prescriptions.
9. Take positive action if you suspect patient addiction or diversion. Public Health Law §3372 requires a physician to report to the New York State Bureau of Controlled Substances any patient who is reasonably believed to be a habitual user or abuser of controlled substances at (518) 402-0707.
10. Refer the patient for treatment of addiction if appropriate, and document this discussion with the patient in the medical record.
11. If a patient is believed to be selling/diverting narcotics, and the patient's random urine test confirms no drug use or there has been a forgery or theft of prescriptions, contact the law firm of Fager and Amsler, LLP to discuss how to discharge the patient and how to handle requests for medications from the patient before the discharge is final.
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Tip #11: Using chaperones during physical examinations (PDF)
The Risk: Practitioners must recognize that, at any time, a patient may make a complaint to the Office of Professional Medical Conduct alleging that he or she was the victim of a physician’s sexual misconduct. Having a chaperone present during intimate physical examinations may be beneficial to both the physician and patient. First, it may provide reassurance to patients, demonstrating both respect for their concerns and an understanding of their vulnerability. Second, the use of chaperones can provide legal protection for the physician in the event of a misunderstanding or false accusation of sexual misconduct on the part of the patient.
1. A practitioner should always use a chaperone when performing breast or pelvic examinations on patients.
2. Consideration should also be given to the use of a chaperone for rectal and/or testicular examinations and in unusual situations where the physician is concerned that the patient, spouse, or family member seems uncomfortable, apprehensive, or otherwise heightens the practitioner’s concerns. Such situations include when a parent or spouse demands to be present, or when a patient acts seductively or otherwise inappropriately.
3. The presence of a chaperone must always be documented in the patient’s medical record. The practitioner can simply document “chaperone in room for the entire exam” and the chaperone’s initials. A template is available from Fager & Amsler from which either a stamp or a form for your electronic medical records (EMR) for this documentation can be made by your office. Adding the name and title of the staff member who chaperoned the exam allows you to verify their presence at a later date, should the need arise.
4. A chaperone should be provided even if the practitioner is the same gender as the patient.
5. Chaperones must be educated about patient privacy and confidentiality.
6. Unless specifically requested by the patient, family members should not be used as chaperones.
7. Respect for the patient’s privacy can be maintained by speaking to the patient privately before and/or after the examination.
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Tip #12: Promoting communication between the referring and the consulting physicians (PDF)
The Risk: Lack of communication between providers can result in a delay in diagnosis or treatment, the failure to act upon abnormal test results or findings, and the duplication of the prescription of, or failure to prescribe, appropriate medications or order diagnostic testing. A lack of clearly defined roles and responsibilities for all physicians may impede your ability to provide and promote safe and effective patient care.
1. Referring physicians should develop a method for determining whether a consultation has been completed and if a written report has been received.
2. As a matter of standard office policy, all consultation reports must be reviewed by a provider, initialed, and dated prior to being filed in the patient’s medical record.
3. Office follow-up procedures should permit easy identification of a patient’s noncompliance with the recommendation for a referral, such as when a written report has not been received from the consultant.
4. If a patient has been non-compliant in obtaining the recommended referral/consultation, follow-up with the patient is necessary. Your discussion with the patient should include reinforcement of the necessity and reason for the referral/consultation, as well as documentation in the patient’s medical record of all attempts to contact the patient and obtain compliance.
5. If a written report from the consultant is not received in a timely manner, you should contact the consultant to determine whether a written report has been generated.
6. Consulting physicians should routinely send written reports to referring physicians in a timely manner. These reports should include:
recommendations, including interventions, and the delineation of provider responsibility for treatment
follow-up of abnormal test results, including incidental findings.
7. To promote effective communication, the consultant should contact the referring physician about any patients who fail to keep appointments. Medical record documentation should reflect the missed appointment, as well as notification of the referring physician.
8. Telephone conversations between referring and consulting physicians are important when clarification of the contents of a report is necessary. Timely contact must be made when an urgent or emergent clinical finding is identified. These conversations must also be documented in the patient’s medical record.
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