Diagnostic Challenges: Understanding Contributing Factors to Reduce Risk The diagnostic process has been defined as a “complex and collaborative activity that unfolds over time and for most patients occurs within the context of the health care work system.”1 In 2014, the Institute of Medicine appointed an independent committee to define the complexities of this process with the objective of improving diagnostic accuracy amongst clinicians. Their diagnostic process map serves as an important reminder that both patients and clinicians play a role in ensuring diagnostic accuracy. June 6, 2025 Member Benefits, Practice Management, RCMA, RCMA/CMA, Resources, Risk Management Business Partner, ProAssurance, RCMA, Resources, Risk Management 0 0 Comment Read More »
Smooth Transitions: The Importance of Handoffs for Continuity of Care The Institute of Medicine (IOM) reported that “it is in inadequate handoffs that safety often fails first." A handoff is a complex process that can happen thousands of times a day in a busy hospital or ambulatory care center. Handoffs occur all along the continuum of patient care between many different members of a healthcare team and across many different locations of care. March 6, 2025 Practice Management, RCMA/CMA, Resources, Risk Management Business Partner, ProAssurance, RCMA, Resources, Risk Management 0 0 Comment Read More »
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. November 4, 2024 Practice Management, RCMA/CMA, Resources, Risk Management Business Partner, Medical Record Documentation, ProAssurance, RCMA, Resources, Risk Management 0 0 Comment Read More »
