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Medical Record Documentation: Paint The Clinical Picture with Complete and Accurate Documentation

Medical record documentation errors continue to play a significant role in medical malpractice claims. Incomplete and inaccurate documentation can lead to a variety of unintended consequences including delayed diagnosis or misdiagnosis, patient harm, and death, any of which can lead to medical malpractice claims. Documentation errors encompass missing or incorrect information in charts, notes, transcriptions, and other electronic health record (EHR)-related areas. Copy/forward and drop-down menu functions, the ability to easily document on the wrong patient or in the wrong location of a chart, and late entries that may appear concurrent are all documentation issues that can cause patient injuries and/or impact the defense of a lawsuit. Certain aspects of the medical documentation process may invite behaviors that contribute to errors and inappropriate notations, increasing the likelihood of later liability.

Is It Safe to Send That Text? The Patient Safety and Liability Risks Associated withText Messaging.

Texting in a healthcare environment has risks and benefits. In the following article, Mary-Lynn Ryan, Senior Risk Management Consultant with ProAssurance shares ways to avoid risk when using text technology in your practice.

Managing the Stressors Driving Physician Burnout

Research indicates that a majority of physicians may be suffering from burnout and that burnout is nearly twice as prevalent among physicians as among other workers in the United States. Who or what is responsible for physician burnout is a complicated question that has prompted a great deal of research over many years. Burnout in physicians has been defined as emotional exhaustion, impersonal reaction to patients, feelings of incompetence, low achievement, and lack of motivation. There are multiple tools to measure physician burnout and wellness. Assessing the problem is a key organizational and personal strategy for ensuring quality patient care and physician well-being.

Liability Risks of Telemedicine: State Standards Among Considerations

Telemedicine utilization growth continues at an impressive rate. According to the FAIR Health database (the largest repository of private healthcare claims), telemedicine use in the U.S. nearly doubled between 2007 and 2015. Over half of all U.S. hospitals now use some form of telemedicine, according to the American Telemedicine Association. Telemedicine is widely credited with improving patient access, cost efficiencies and quality of care. This and increasingly favorable state and federal telemedicine legislation may explain the rapid increase in its utilization. Despite the advantages, telemedicine has liability risks, such as privacy, security, patient confidentiality, credentialing and misdiagnosis due to a lack of continuity of care. Additionally, the soft skills that may come naturally in a personal patient encounter may need to be adjusted for electronic encounters. Telemedicine providers should evaluate their “webside” manner. For example, equipment needs to be positioned to simulate direct eye contact; active listening cues may need to be exaggerated; posture and facial expressions may need adjustment and sessions must be started and ended appropriately. Seemingly minor electronic communication strategies can significantly affect the success of a telemedicine encounter.

Reducing the Risks of Abandonment Claims

Terminating a physician-patient relationship is appropriate and ethical in a variety of circumstances. However, if the relationship is not ended appropriately, a physician could be liable for patient abandonment or for failure to diagnose or treat a condition.

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