Doctors Must Properly Document Services


To avoid the risk of a malpractice suit, doctors should help themselves with proper documentation of their services as a form of risk management. This can greatly help physicians, and the facilities where they work, in their efforts to improve the quality of patient care while reducing any liability exposures they could wind up facing. It’s also important to have adequate medical professional liability insurance on hand to aid with claims or any ensuing defense costs.


Maintaining patient confidentiality


Office staff should be properly trained in the scope of their duties in line with office practices. They should refrain from discussing patient information openly since such acts could breach patient confidentiality. Educating your staff about their need to maintain patient confidentiality is crucial and they should never be allowed to discuss any aspects of patient care outside of the office.


In addition, ensure that your patients are receiving any necessary testing and follow-up procedures as this is of the utmost importance. All test results should be returned directly to the office promptly for the proper review. Patients should be informed of the facts concerning their condition and the need for any additional testing, and doctors should be documenting these conversations.


Avoiding malpractice claims


Some patients may be susceptible to side effects, allergic reactions, or fall victim to errors in the prescribing of medication. There are dangerous risks associated with many drugs being prescribed today, so physicians ought to be discussing this information with their patients, again documenting these discussions in their medical records.


As a physician, you should be making patients aware of any possible outcomes, both positive and negative, from any procedures they might agree to undergo. Include the patient in the decision-making process since this can help to prevent allegations of malpractice. By effectively documenting all discussions you can help to address erroneous or false charges in court, and show proof when you are wrongly accused.


Documentation is an effective way of communicating with your staff. But in instances where malpractice allegations are made, a plaintiff’s attorney, or arbitrators will review your records in an attempt to discredit your testimony. Always keeping accurate records, and having medical professional liability insurance can make the difference.