The lifetime risk of a primary care physician facing a malpractice lawsuit is 75%, according to a study by researchers from the University of Southern California, Harvard University and the RAND Corp. While medical coding companies can help physicians avoid malpractice claims through accurate coding of the diagnosis, providers need to implement best practices to prevent getting sued for medical malpractice.
- Ensure comprehensive documentation in the electronic health record (EHR): EHRs enable complete documentation and timely access to patient information, facilitating sound clinical decision making. The golden rule is: “if you didn’t document in the chart, you didn’t do it”. Physicians must ensure complete information about the patient’s medical case and claims processing decisions. Each patient record should be customized and the clinical encounter faithfully reported as it occurred.
In a report in Medical Economics, experts recommend documenting all conversations – “summarizing patient discussions, having patients verbalize their understanding of why something is important, explaining why any clinical alerts are dismissed and noting conversations with other providers or with family members”. Physicians should never make any alterations in the record, but can include an addendum if needed. Lack of thorough documentation increases medical malpractice risks.
- Double-check EHR documentation: However, documenting in the EHR can be complex, and most physicians find it difficult to manage along with patient care. EHR templates are designed to improve documentation efficiency, but physicians need to pay attention when using them. Computerized data entry by physicians can cause errors, as many studies show.
A study published in the New England Journal of Medicine in 2010 reported that discontinuities between information systems may result in prescribed medications being automatically canceled without a warning. Further, increased access to the patient’s information via EHRs may encourage providers to use previously recorded patient histories, test results, and clinical findings rather than collect and enter new information. This will lead to errors and omissions from earlier encounters. They may mistakenly click the wrong item in a click-down menu. Indiscriminate use of the copy and paste function of EHRs can also perpetuate previous mistakes. Therefore, before administering tests or prescribing medications physicians need to double-check their work and review the entire patient record, say legal experts.
- Ensure clarity in communication with patients: Critical information must be clearly communicated to patients so that this no misunderstanding. Lack of critical information, misinterpretation of information, and unclear orders can put patient safety is at risk and lead to medical errors, and even severe injury and death.
One way of improving clarity and fostering patient engagement is to share notes with patients, says the Medical Economics report. Physicians can review notes with patients and explain to them about their treatment, including tests and procedures, medical billing, and so on. Patients should never be allowed to directly make changes in their chart, and any additional information should be entered as an addendum. Further, physicians should ensure that all entries are based on facts, and relate to medical specifics of a visit, call or referral. Note should be notes objective, impersonal and unambiguous, and not derogatory in any way. These measures will reduce the potential for malpractice claims due to miscommunication or misunderstandings.
- Be alert while prescribing medications: According to a 2002 study of medication errors in 36 health care facilities, up to 19 percent of doses were erroneously prescribed. Common errors included giving the medication at the wrong time or not at all, incorrect dosages and unauthorized drugs. Serious errors also occur with controlled medications. Though e-prescribing can reduce the incidence of medication errors, physicians need to be extra cautious and ensure clarity while making out prescriptions. Abbreviations of drug names and preparations should be avoided as they can be misinterpreted, for e.g., HCT (hydrocortisone) can be confused with HCTZ (hydrochlorothiazide).
To avoid risk of errors, all medications and treatments should be reviewed at each patient encounter.
- Ensure HIPAA compliance: Physicians should ensure that their practice is HIPAA compliant. Staff should be trained on the state’s HIPAA rules on a regular basis and educated about the importance of maintaining confidentiality of personal health information (PHI). All devices or laptops storing PHI should be protected with top-notch security measures. Besides potential lawsuits, data breaches can cause reputational harm and prove costly in terms of mitigation, sanctions, patient notification, and reporting.
- Avoid intentional and accidental coding errors: Physicians should make sure their patient records accurately reflect services rendered. Upcoding occurs when the code documented is at a higher level of complexity. It is often the result of copy-pasting EHR notes from a patient’s previous visit into the current treatment note. This would make it seem that the provider has diagnosed and treated all condition on that list. Whether upcoding is done intentionally or accidentally, it can have serious implications and lead to allegations of fraud.
Providers and their staff should avoid such coding errors and ensure that there is sufficient documentation to support all claims. In reliable medical coding companies, the team would clarify anything that is questionable in the documentation with the physician before assigning codes and submitting claims to insurance companies. They will also audit claims to detect errors or trends that need correction.
- Have empathy and maintain good relationships with patients: Studies have shown that low malpractice rates may indicate patients’ reciprocation of their physician’s empathy. Physicians can maintain good relationships with patients by ensuring transparency and being realistic. They should communicate the expectations for treatment, follow up, and medication to patients and their families. The Medical Economics report says that helping patients understand their situation thoroughly, care can be improved, thereby reducing the likelihood of misunderstandings and potential lawsuits.
Physicians should be realistic and well-informed about the risk of malpractice lawsuits and review their malpractice insurance coverage every year. Partnering with an experienced medical billing and coding company will ensure accurate and responsible claim submission in keeping with the guidelines.