Insured Assignments

Credentialing is required for everyone who performs medical services. Today we are 

focusing on medical practice employees. Why? Approximately 40% of lawsuits involve activity performed by non-physician providers of medical services in outpatient offices. So what should we do to protect patients as best we can and to limit our own liability?

Here are a few simple but essential practices to put in place: First, each employee with clinical responsibilities in the practice should have a list of medical services that they are approved to perform. They should be approved to perform these services by an office medical supervisor or a physician who certifies that they have been given the instruction and training necessary for the tasks, and that they are qualified and competent to perform these services. Second, maintain documentation verifying each employee’s instruction: whether they have received formal training in a  credentialed school program, or on-the-job instruction.

If an error is made, it will be recognized as a mistake by a trained and competent employee, rather than an employee who was negligently allowed to perform services for which they did not have the proper training and credentials. Either way the lawsuit will have to be defended, but much more leniency is shown for “human error” than for situations in which an employee injures a patient by performing a procedure they did not have proper credentials to perform in the first place. 

Careful attention to credentialing and documentation is essential. It protects our  patients by ensuring that they receive competent care, and protects our staff and  business by limiting our liability.

In light of some recent events, I want to make sure you are fully informed that any incident that results in an undesirable outcome is an “Incident,” and we want to know about it. If it becomes a law suit, it helps if we receive the information early while things are still fresh on the minds of those involved. More importantly we try to prevent law

suits which is our greatest goal. 

You are intimately involved in all of this. It is vitally important that you understand the conditions set for you in your policy. Under the section “Your Duties if You Have a Claim” state: 

You and any other covered person named in the claim (or involved in the incident) MUST: 

“Tell us about the incident. Include the date, time, and place of the event; what covered activity you performed; and the names and addresses of any injured people and any witnesses.” 

“Refrain from admitting liability, assuming any financial obligations, or paying out any money without our authorization. If you do, we will not reimburse you, even if the cost is covered by this policy.”

“If you fail to comply with your duties under this section, your failure could seriously impair our ability to appropriately defend your claim and we may deny coverage under this policy.”

Please call us to discuss any incident that you might be concerned about. Kathleen Conway (510-316-2348) or Jerry Kitchens MD (205-542-5139). Of course you have to submit a signed incident report as well. Fortunately, these are available on the website.

As most of you know, part of our underwriting includes an assessment of hospital or ASC records. What you may not know is how the scores are generated. In an effort to improve documentation and to be fair to our insureds, the following is our instruction sheet for the evaluators. I think you will benefit from reviewing this document and applying it to your practice.

Progress Notes

Progress notes are to record the status of the patient and plans implemented in response to that status. There are many areas that are important to include in progress notes. It is important to recognize notes written on lab reports, EKG strips or other forms may not be included in the final medical record, paper or EMR.

Clinical data reports (lab, radiology, studies, consults) should be mentioned in the progress notes. Abnormal results deserve special attention. It should also be recorded if a lab result is expected but not yet available. Score 2 if consistent reference to clinical data; 1 if occasional reference; 0 if hardly any reference.

Course of patient should be properly described. Terms such as “no change” or “doing well” provide no useful information and is not complete enough

for a patient whose condition is critical or deteriorating. The main reason for the patient’s hospitalization should be addressed. Reference to new developments, positive or negative, should be mentioned. This will include things such as eating, skin condition, ambulation, mental status, etc. There should be enough information in the progress notes that another physician who might be providing on call coverage can know what is going on from the progress notes. Score 2 if status of the patient is well described; 1 if there is some description but should be more; 0 if the reviewer has major questions about what is happening to the patient and cannot find the answers in the progress notes.

Minimal notes are acceptable for routine patients without complications. More complete descriptions are necessary for complex cases.

Assessment and Plan Each progress note should conclude with an assessment of the patient’s status and plans in response to that assessment.

Assessment and plan may be inferred from the rest of the note in a very normal, stable, or improving patient. Any new development or change of plan should be explained. It might be as simple as “Patient continues to improve as expected” “No change in management”. It might also have a list of current problems and new developments. Any change in management

needs to be specifically noted and the reason for these changes made clear. This will benefit the patient by providing information to other physicians involved in the care of the patient. Score 2 if assessment and plan are in each progress note; 1 if occasional assessment and plan; 0 if no assessment and plan. Minimal notes are acceptable for routine patients without

complications.

Documents

History and Physical – Medical The admission history and physical should be complete. It should include all elements physicians were trained to

include, including vital signs which for some reason is often omitted. For medical admissions it should have a working diagnosis and appropriate

differential diagnoses. The plan of diagnosis or treatment should be clear. For procedural (surgery or any invasive procedure) admissions it should

present sufficient evidence that the proposed procedure is warranted. It should be thorough enough to identify or exclude all real and possible risk factors that might be affected by the procedure. Medical admissions should have the H & P dictated within 24 hours of admission or a notation that the patient was seen pre-op and no changes since the H&P was dictated. This notation should be signed, dated, and timed.

2 if diagnosis and plan are clear; 1 if one or the other is incomplete; 0 if not present or inadequate

Score for procedural admission:

2 if H & P justify the procedure: 1 if it is justified but some elements are missing; 0 if inadequate

2 if risks are appropriately addressed; 1 if OK but could be more; 0 if inadequate

Score for timeliness of medical admissions:

2 if completed within 24 hours of admissions; 0 if over 24 hours

Informed Consent The informed consent needs to be discussed and signed. The discussion of risks needs to be documented either in the admission

H&P or Op note. The discussion of risk should have phrase “included but not limited to” and include the most common complications. There needs to

be a note that the physician affirms the IC has been signed. If the time out is noted in the operative report, this will suffice for consent being signed.

Score: 2 if there is a note that indicates the risks have been discussed in detail and questions answered; 1 if both elements are not included;

0 if not mentioned.

2 if note is made that IC has been signed; 0 if no mention of IC signed is in chart. See note above.

Procedure Note

Time out includes identification of patient, surgical site, procedure, informed consent, pre op meds, administration of preop antibiotics if indicated.

Score: 2 if mentioned in op note; 0 if not mentioned.

Pre procedure dx and post procedure dx. Score: 2 if both present; 1 if only one present; 0 if neither present.

Prep: (positioning of the patient; scrub and drapes). Score: 2 if all (indicated) mentioned; 1 if one is missing and indicated; 0 if none mentioned.

Procedure adequate description of procedure with thorough description of any complications that occurred and steps taken to deal with them. Score 2 for complete note; 1 if not much detail; 0 if bare minimum.

Counts The conclusion of the procedure report should include all applicable counts, “reported as correct” is acceptable, just stating correct is not, and EBL. Score 2 if all applicable counts mentioned; 1 if some but not all applicable counts mentioned; 0 if no applicable counts mentioned.

Timeliness Dictated within 24 hours of the procedure. Score 2 if dictated 

within 24 hours of procedure; 0 if not.

Ambulatory Surgery

Preop screening For patients who receive anesthesia from a non- supervised CRNA, the patient was screened by an appropriate person and assigned an ASA Class 1 or 2. Score 2 if this is documented; 0 if this is not documented.

Instructions

It is important to document that discharge instructions were given to the patient. Score 2 if documented; 0 if not documented

There must be documentation that the patient is instructed not to drive or operate machinery for 24 hours after anesthesia. Score 2 if documented; 0 if not documented. This can be by order, surgery

facility policy or in the office at pre-op visit.

Discharge Summary

Hospital Course There is adequate summary of events and data pertinent to the admission.

Instructions to Patient Discharge instructions, written or verbal, are documented

Follow up Plans Appointments made or need to be made are documented.

Timeliness Within in 30 days of discharge or sooner if By-laws require sooner.

Critical or Deteriorating

Consults are important to request when complications are present and input from other specialists would be helpful. This usually indicates a significant problem and demands urgency. It is important to verbally communicate with the physician being consulted when the consult is initiated. This verbal communication must be documented in the progress notes. It is important

to acknowledge the consult report when it arrives and also make note if a consult is not done timely. Any additional calls to the consultant should be

noted. Score: 2 if consults and calls made for consults are referenced in the progress notes; 1 if consult is mentioned but no mention of calls made; no reference to the initiation of the consult in the progress notes.

Reports from Nurses (verbal and written). The nurses have important information about the patient. Due to increased administrative duties there tends to be less personal interaction between the physician and nurse.

Written nurse’s notes are becoming more important. At times a nurse may record an exam that is very much different than what the physician records.

Also, the nurses may not write their note until the end of the shift which might be after the physician has made rounds and made a note. Another

reason to time progress notes. Score 2 if consistent reference to nurses notes or verbal report from the nurse; 1 if there is occasional mention of the

nurse’s notes; 0 if there is no reference to the nurse’s notes. 

Minimal notes

are acceptable for routine patients without complications. Next year, this item may be placed into a separate category and focus on complex patients or ones with significant complications.