Risk management

• Q: Are your required to provide sharps containers in the business (non-clinical area) for personal needles? What is the OSHA requirement on this?
• Q: Can a physician evaluate a patient outside the office and document the encounter as long as he does not bill the insurance company? When this physician visits a neighboring city he is from, the people want his opinion. He examines them and gives them advice. He would like to document his encounters so they do not have to come multiple times to the office.
• Q: Patient John Doe had Surgery with Dr Fixit a week ago. Dr consulted with pain management during initial post op consult in the hospital. During hospital stay patient became agitated, violent, reportedly threw objects at hospital staff and discharged himself against medical advice. Patient reportedly stated that he could find better drugs on the street. His PICC line was pulled prior to discharge. Dr Fixit does not feel it is safe to continue treating this patient in the office. Can the Dr discharge the patient from practice since it is only a week from surgery. Does Dr Fixit have to do a post op visit and then discharge??
• Q: Does limiting documentation of screening (Review of Systems, Past medical History, BP etc) of the patient decrease or increase liability?
• Q: What standard guidance can you give us in the event that we experience a HIPAA breach of PHI that only involves less than 500 patients and no patient financial information was disclosed?

Q: Are your required to provide sharps containers in the business (non-clinical area) for personal needles? What is the OSHA requirement on this?

A: Under the OHSA Bloodborne Pathogens Standard, sharps containers must be easily accessible to employees and located as close as feasible to the immediate area where sharps are used (e.g., patient care areas). The NIOSH list of inappropriate sharps container locations includes in the corners of rooms, on the backs of doors, under cabinets, on inside cabinet doors, under sinks, in areas where people might sit or lie beneath the container, near light switches or room environmental controls, or where the container is subject to impact from pedestrian traffic or moving equipment.

Disclaimer:

This is by no means legal advice. There may be additional liabilities that you may need to seek legal advice for.

Q: Can a physician evaluate a patient outside the office and document the encounter as long as he does not bill the insurance company? When this physician visits a neighboring city he is from, the people want his opinion. He examines them and gives them advice. He would like to document his encounters so they do not have to come multiple times to the office.

A: According to the AMA, consulting with a patient outside an exam room in an informal setting in no way lessens legal liability. Physicians should be very cautious in conversations in an informal setting because some courts have ruled the conversation can be enough to create a physician-patient relationship in which a physician can be held liable for a bad outcome.

If possible, it is best to tell the patient to come in the office the next day for an appointment, or if it is an emergency, to be evaluated at an emergency department. However, for physicians, encounters such as the example you provided are often unavoidable. It is important for physicians to remember they carry the responsibility and the liability of being a physician with them wherever they go.

As there are potential risks for providing medical advice without a full written history on a patient, physicians should always be very careful about giving medical advice and should not do so without a signed consent to treat document. The only situation in which a consent to treat document is not signed before treatment would be in the case of an emergency. This document protects physicians from liability.

If the patient is an established patient with the physician, we would recommend documenting the encounter in their chart. If the patient is not established, we would recommend keeping a secure file with documentation of the encounter. One of the best ways to protect against liability is through documentation. The physician should have a medical history for the patient.

Disclaimer:

Information was provided by Healthcare Compliance Pros support. This is by no means legal advice. There may be additional liabilities that you may need to seek legal advice for.

Q: Patient John Doe had Surgery with Dr Fixit a week ago. Dr consulted with pain management during initial post op consult in the hospital. During hospital stay patient became agitated, violent, reportedly threw objects at hospital staff and discharged himself against medical advice. Patient reportedly stated that he could find better drugs on the street. His PICC line was pulled prior to discharge. Dr Fixit does not feel it is safe to continue treating this patient in the office. Can the Dr discharge the patient from practice since it is only a week from surgery. Does Dr Fixit have to do a post op visit and then discharge?

A: Normally terminating a patient during a post-operative period is not a good idea unless he can find another physician that is willing to take him on as a patient. Of course there is no excuse for his behavior, but maybe the pain or the drugs created a violent reaction. It may be a good idea to do a post op visit in the office and see how the patient acts. This would be the time for Dr. Bacon to lay down some ground rules, one being that if his behavior continues, than he will not treat him. Unfortunately there is no definite answer when it comes to termination. Here is a link to a TMLT reporter article about termination of a patient relationship (see page 5). I have also attached some sample termination letters and TMA whitepaper.

The leaving AMA should be documented in his hospital chart. Only the facts of the situation should be documented.

Disclaimer:

Wendy Kaliszewski has provided the following resources for termination of the patient-physician relationship, which should only be used as information for each practice to decide individually how to handle the circumstances of a particular patient. The information provided in no way constitutes legal advice, and is meant as general information only. Gallager Healthcare was agent who assisted in obtaining the information.

Q: Does limiting documentation of screening (Review of Systems, Past medical History, BP etc) of the patient decrease or increase liability?

A: The review of systems should reflect the care of the treating physician. The review of systems would be different for a follow up on certain conditions versus a surgical candidate. The physician may choose to limit the review of systems for a routine visit, but a full review of systems may be appropriate for pre and post op patients. If a patient reports an issue in the review of systems that is not an orthopedic issue, than the physician should at least document that it was addressed and the patient was referred to another physician for that issue. Many specialists refer patients back to the PCP to treat high blood pressure, diabetes, depression, yet it may be important information for the orthopedic physician to have prior to surgery.

The past medical history is important and a requirement by the Texas Medical Board as what should be in an encounter note. Here is the link to TMB 165:

Below are the sections for easy access.

Chapter 165. Medical Records

§165.1. Medical Records.

Contents of Medical Record. Each licensed physician of the board shall maintain an adequate medical record for each patient that is complete, contemporaneous and legible. For purposes of this section, an “adequate medical record” should meet the following standards:

• The documentation of each patient encounter should include:
  • reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
  • an assessment, clinical impression, or diagnosis;
  • plan for care (including discharge plan if appropriate); and
  • the date and legible identity of the observer.
• Past and present diagnoses should be accessible to the treating and/or consulting physician.
• The rationale for and results of diagnostic and other ancillary services should be included in the medical record.
• The patient’s progress, including response to treatment, change in diagnosis, and patient’s non-compliance should be documented.
• Relevant risk factors should be identified.
• The written plan for care should include when appropriate:
  • treatments and medications (prescriptions and samples) specifying amount, frequency, number of refills, and dosage;
  • any referrals and consultations;
  • patient/family education; and,
  • specific instructions for follow up.
• any written consents for treatment or surgery requested from the patient/family by the physician.
• Billing codes, including CPT and ICD-9-CM codes, reported on health insurance claim forms or billing statements should be supported by the documentation in the medical record.
• Any amendment, supplementation, change, or correction in a medical record not made contemporaneously with the act or observation shall be noted by indicating the time and date of the amendment, supplementation, change, or correction, and clearly indicating that there has been an amendment, supplementation, change, or correction.
• Salient records received from another physician or health care provider involved in the care or treatment of the patient shall be maintained as part of the patient’s medical records.
• The board acknowledges that the nature and amount of physician work and documentation varies by type of services, place of service and the patient’s status. Paragraphs (1) – (11) of this subsection may be modified to account for these variable circumstances in providing medical care.

Disclaimer:

Wendy Kaliszewski (TMLT Insurance ) has provided the following suggestions for medical record documentation, which should, of course, be modified for the circumstances of a particular patient. Records should always conform to the standards set forth in TMB Rule 165.1.

Q: What standard guidance can you give us in the event that we experience a HIPAA breach of PHI that only involves less than 500 patients and no patient financial information was disclosed?

A: Under these facts, you will need to complete the following steps regarding this minor breach that occurred in your office:

• Notify all affected patients about the breach. You may use our Breach Notification Letter as a template.
• Document the breach in each affected patient’s chart. Include a copy of the Breach Notification Letter.
• Also document the breach in your HIPAA Breach Log. Re-train the employee(s) who caused the breach.

Have the employee(s) complete his/her HIPAA Privacy and HIPAA Security training. If they have taken it already, they will need to re-train. If they are using our services, then when they login to their account, simply tell them to click “Retake” next to the HIPAA courses and complete them.

(The above-referenced forms can be provided by contacting Healthcare Compliance Pros)

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