A Risk Management Checklist - Part II

Proper risk management is about meeting and fulfilling reasonable expectations for the various elements of the practice. These include adequately documented medical records, documented billing and collection guidelines, documented employee screening, training and safety, and environmental safety and comfort. This is the second in our series of Risk Management Checklists. The last issue's article included: Documentation of Medical Records; and Medications. This issue will deal with the four remaining items: Consent Issues; Billing and Collections; Employee Files and Training; and the Practice Environment.

Consent Issues

- Are consent discussions between the doctor and patient documented including:

a) Discussion of risks, benefits and alternatives

b) Documentation of a refusal of any or all of the physician's recommendations and warnings from the physician

c) Does consent documentation for statutory procedures comply with state law?

- Are written consent forms used? Are they regularly reviewed?

- Is there documentation of support staff involvement in the consent process such as education efforts and witness of informed consent?

- Are educational materials used in the consent process and are these made part of the record and then archived when replaced or updated?

- Is the patient's ability to give informed consent indicated when appropriate?

- Is telephone consent documented/

- Is patient follow-up documented as routine, required or required within a certain time frame?

- Is there written documentation of consent from third parties such as custodial parents, legally incompetent adults, guardians, foster parents, courts, etc.?

- Is there documentation of consent discussions when an interpreter was required?

Billing and Collections

- Is there documentation that the patient was informed about billing, insurance and collection procedures?

- Is there documentation the physician has reviewed the record before a patient's account is sent to collections?

- Are all claims for payment supported by adequate documentation in the medical record for the medical necessity of the particular level of service?

- Does the practice have a program for physicians and employees to make certain the practice is in full compliance with billing requirements?

- Is there a mechanism in place that allows employees to inform superiors about discrepancies in billing without fear of reprisal?

Employee Files and Training

- Is there documentation of an Illness and Injury Prevention Program for staff?

- Is there documentation in the employee's record on:

Continuing education?
Information on new licenses and renewals?
Certification in Basic Life Support if appropriate?
TB testing?
Training in use of specialized equipment or protocols?
Hepatitis vaccine offered? Documentation of refusal?
Reference checks?
Documentation of specialized training?

- If drug screening is required, is prospective employee approval given in the application?

- Are applications retained for at least one year or the statutory period?

- Are employee and family medical records kept separate from other patients' records?

- For licensed employees, is there a copy of a current, valid license on file?

- Are records maintained for required continuing education?

- Is there a copy of the DEA certificate on file?

- Is there a copy of the NPDB (National Practitioner Data Bank) report on file?

- Are records maintained of staff meetings, decisions, action items, responsible parties, etc.?

- Are required notices displayed in employee lounge areas?

- Are proper time records maintained for employees and compliance with overtime requirements (federal and state)?

Practice Environment

- Is the reception area clean and comfortable?

- Are educational materials available and up-to-date? Are they stamped with practice name and address?

- What is the average patient waiting time in the reception area and in sub-waiting areas including the exam room?

- If the patient schedule is changed, is there documentation of the change and the notification to the patient?

- Is staff instructed in activating an emergency response such as 911?

- Is the emergency resuscitation equipment and medications checked frequently and documented?

- Are medications checked at least monthly for expiration dates or is there a list of emergency medications with expiration dates?

- If a defibrillator is used, is it tested and documented regularly?

- Is emergency equipment and medication readily available and secure?

- Is staff trained in using the equipment?

- Can others overhear discussions with patients on clinical, personal or financial matters in the reception area?

- Is there a private area for confidential discussions?

- Are medication refrigerators separate from employee refrigerators?

- Are all areas of the practice clean and free of debris?

- Are biologics properly disposed of including appropriate containers for sharps?

- Are hallways and patient care areas kept free of obstructions?

- Are OSHA requirements with regard to hazardous substances followed including all required logs?

- Is the lab properly certified for CLIA (Clinical laboratory Improvement Act) including all record keeping requirements, staff training and supervision appropriate to the CLIA level?

- Are medical gases stored safely?

Better Safe Than Sorry - In most cases good practices are doing the above-mentioned items on a regular basis. If there is any problem at all it is with the documentation of the work being done and the timing. The best way to take care of these items is to have a regular schedule for double-checking the items to see that each is being done. It is also a good opportunity to delegate jobs to different people in the practice. Make sure the assignment is one they are qualified to perform and evaluate and then make sure they report on their findings, corrections and recommendations. Practices that make safety, security and good documentation a part of regular patient care will minimize the risks of a modern practice and create an excellent environment in which to work and be a patient.

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