The Top Three Things to Know about the Top Three Risk Management Issues
by Charles D. Cash, JD, LLM
Mr. Cash is Assistant Vice President at PRMS, Inc. in Arlington, Virginia.
Funding: No funding was provided for this article.
Disclosures: The authors reports no conflicts of interest relevant to the content of this article.
Answers in this column are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and onsite risk management audits, and other resources to healthcare providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers may provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so “clinician” is used to indicate all treatment team members.
Reprinted with permission from Innov Clin Neurosci. 2019;16(3–4):31–32. © Copyright Matrix Medical Communications, 2019.
Question
I am always interested in improving patient safety and reducing my professional liability risk. I would also like to know that I am not alone in what I worry about in my practice. In providing risk management consultations, what are the most frequent risk management topics about which physicians ask? As a physician in a busy private practice, what are the most important risk management steps that I should implement on those topics?
Answer
Here are the top three risk management issues about which we are asked, along with their risk management pearls. Sometimes these vary in the short-term, but over time, physicians have consistently shown the most interest in these topics.
Requests for Information. Treatment records are the most frequently requested type of information a physician might receive. At some point, patients might want to see their records or obtain a record copy. Patients generally enjoy a robust right to access and/or obtain copies of their treatment records. This includes records kept by the treating physician but created by another provider. It also might be necessary for a patient to request the release of his or her medical records to someone with adverse interests, such as the opposing attorney in a patient’s divorce proceeding. Appropriately descriptive wording that accurately captures the clinical situation of the patient is most important when documenting a patient’s treatment. However, the physician might consider using words the patient might find least upsetting should he or she ever read his or her treatment records. Consider also whether the information is clinically relevant and just how much detail is needed before including it in the record. Consider the following three pearls:
The physician should not delay in responding to requests for information. It is vitally important that requests for information be addressed quickly because there are professional, ethical, and legal penalties for failing to respond in a timely manner. Furthermore, failure to respond appropriately to requests in a judicial context might invoke professional liability coverage issues. Responding to a request for information does not always involve disclosing the information. In fact, frequently it does not. Even if the request will be denied and information will not be released, a response should be a made in a timely manner. Many states specify a response deadline to requests for information.
A bare subpoena might not be sufficient to release information. A subpoena is a legal document used to obtain the testimony (written or oral) of a witness in a legal proceeding. Subpoenas are usually issued by an attorney, but while attorneys have the authority of the court behind them, their requests do not carry the same weight as actual court orders. Often, a subpoena alone is not sufficient to compel the release of medical records. This does not mean, however, that a subpoena can be ignored. Subpoenas require a timely response, even if no information is released.
The threshold for denying access to a treatment record copy is high. A written request with a proper release authorization almost always compels a physician to release a health record copy, even if he or she does not wish to do so. For example, information can be withheld if disclosure would cause the patient to become imminently suicidal or homicidal, but information cannot be withheld if it would simply cause the patient to become angry and file a lawsuit. Some states and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule allow physicians to refuse to release treatment information that might be detrimental to the patient; however, there is typically an appeal mechanism under which the patient can have the physician’s denial of access reviewed.
Documentation. As with most aspects of clinical practice, proper documentation is a skill that requires ongoing learning and assessment to ensure it meets continually evolving demands. Consider the following three pearls:
Documenting the “why” is important. Judges and juries give great deference to physicians when they understand why the physician did what he or she did. Detailed explanations of the physician’s decision-making will substantiate his or her clinical choices and demonstrate that the physician exercised professional judgment to achieve optimal outcomes for the patient. Documenting what the physician didn’t do and why he or she did not do it might be considered just as important as documenting what he or she did do and why.
Be familiar with documentation standards promulgated by your licensing board. State professional licensing boards often have standards regarding documentation with which physicians must comply. Failure to follow state regulations might be a breach of the standard of care.
Never alter a treatment record after an adverse event. An altered or falsified record will be indefensible if discovered (and they almost always are). Additionally, treatment record falsification might be considered a crime and/or constitute professional misconduct. This admonition also includes proper corrections to the record. A treatment record is considered trustworthy for evidentiary purposes because the documentation is created before any adverse event has occurred. Post-event documentation is inherently self-serving and not trustworthy. For proper corrections to the treatment record post-event, it’s best to seek the assistance of risk management or legal counsel so as not to compromise the evidentiary sanctity of the record.
Termination of the treatment relationship. Per the American Medical Association (AMA) Code of Medical Ethics Opinion 1.1.5, “Physicians’ fiduciary responsibility to patients entails an obligation to support continuity of care for their patients.” Once a treatment relationship has been established, the physician has an ethical and legal obligation not to abandon his or her patient and must continue to care for patients until treatment has ended, the relationship is properly terminated, or care has been transferred to another provider. Consider the following three pearls:
If a physician decides to unilaterally terminate treatment, sufficient notice of the need to end the treatment relationship is key in avoiding an accusation of abandonment. The length of the termination notice might depend upon the patient’s condition and available healthcare resources in the community. Usually, 30 days’ notice is considered adequate; however, individual state licensing boards or managed care contracts might require a different notice period. In areas where it might be difficult to find another treating physician, it might be appropriate to give longer notice. The physician should always provide the patient with a specific termination date after which the physician will no longer be available.
Educate the patient on his or her treatment needs and available resources. It is important to give explicit treatment recommendations to the patient and to educate the patient about the need for continued medical care, if necessary, and the potential risks of not obtaining recommended treatment. This should also include detailed instructions regarding medications. Physicians should include the name and dosage for each medication, as well as any other important information in the treatment recommendations prior to termination (e.g., the danger of stopping a medication abruptly). Unless the patient no longer needs treatment, the physician must provide the patient with suggestions for finding continued care. This does not mean the physician needs to provide specific names of other physicians willing to see the patient. Suggesting that the patient look to his or her primary care physician, his health insurance panel, a referral service, or a local clinic are all acceptable. A letter should be sent to the patient memorializing the discussion. The letter should also include instructions for how to obtain a treatment record copy for the patient’s new physician.
Persisting in a treatment relationship that has run its course and inadvertently re-establishing a treatment relationship should be avoided. There are many valid reasons for a physician to terminate treatment. For example, the patient might have medical needs the physician is unable to meet. It is also acceptable to terminate a treatment relationship with patients who are nonadherent to the treatment plan, are overly demanding of the physician’s and/or staff’s time, do not pay fees, or have breached the physician’s trust. Giving treatment advice and writing or refilling prescriptions beyond the date of termination might be seen as re-establishing a treatment relationship with the patient and assuming all of the ethical and legal obligations that go along with it.
Conclusion
While the answer above describes the top three risk management issues that we are asked about, these are not the greatest professional liability risk exposures. Readers are encouraged to review available resources on these topics from their professional societies and licensing boards.
Category: Past Articles, Risk Management
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