Risk Solutions

Medical Records Management & Practice Management

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Course Description

A complete medical record promotes quality patient care by providing a comprehensive patient history and facilitating continuity of care among all members of the healthcare team. When an unanticipated outcome occurs, medical records are often called into question. If the records are poorly maintained, incomplete, inaccurate, illegible, or altered, a patient’s attorney may file a lawsuit, particularly if the medical record causes doubts about the quality of care rendered by a healthcare provider or organization. Conversely, a patient’s attorney may think twice about filing a lawsuit if the record accurately and completely reflects good, quality care provided to the patient.

Conscientious medical practice management— which encompasses working with non-physician staff members and allied health practitioners, developing policies and procedures, evaluating patient satisfaction, being aware of practices that could constitute fraud and abuse, and taking the appropriate steps to close a practice—can have a positive impact on patient care and help reduce professional liability exposure.

This course reinforces the importance of the medical record in reflecting quality patient care, and assists practices in identifying and reducing liability exposures in their day-to-day operations.

Who Should Take This Course

• This course is intended for healthcare practitioners who provide direct patient care and their administrative staffs.

Educational Objectives

By implementing the risk management recommendations herein, participants will be able to:

• Endure fewer and/or less costly malpractice claims by adopting medical record documentation practices that 1) facilitate the continuity of care, and 2) optimize the defensibility of that care.
  
• Appreciate the need for and acquire resources to improve medical record security, retention and release in compliance with HIPAA and state privacy regulations.
  
• Appreciate liability risks associated with working with other physicians and non-physician staff members, and acquire resources and tools to protect patient safety and limit vicarious liability exposure (e.g., written job descriptions, employee policies and procedures, credentialing, performance appraisals, continuing education).
  
• Understand the relationship between patient satisfaction and loss prevention, and implement tools for evaluating and improving patient satisfaction (e.g., patient satisfaction surveys).
  
• Implement a comprehensive equipment maintenance program that ensures patient and employee safety in the medical office.
  
• Articulate a basic understanding of how a physician may be vulnerable to a healthcare fraud investigation, and implement measures, especially a compliance program, that will help minimize the risk or consequences of an investigation.
  
• Design a well-coordinated plan and provide a smooth transition for patients in the event of a practice closure, including notification of patients and agencies, and appropriate medical record transfer and retention.

Expert Reviewers

Bradford S. Dunkin, MHA
Risk Management Specialist III, NORCAL

Diane Post, MA
Risk Management Specialist III, NORCAL

Robin Webster, MHA
Risk Management Supervisor, NORCAL

Accreditation Statement
NORCAL Mutual Insurance Company is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement
NORCAL Mutual Insurance Company designates this educational activity for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Original release date: August 1, 2008
Expiration date: August 31, 2011