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Frequently Asked Questions: General Topics

Q. Does “dictated but not read” suffice in lieu of proofing all of my dictation?
A. No, it does not. You are responsible for the content of your dictation. You should read everything that you dictate, write, or sign. Documentation errors may result in medical errors—for example, “right” being transcribed instead of “left” when identifying a surgical site.

Q. Do all medical record entries require a signature?
A. Yes. There should be guidelines governing medical record documentation and authorship:

• Keep a master list of names, initials, and signatures.
• Use the full last name if staff members have the same initials.
• Allow only the owner of a signature stamp to use that stamp.
• Provide guidelines to the appointment staff for documenting in the medical record.

Q. What resources are available for state regulations of practice?
A. Check with your state board of medicine or with the Medical Group Management Association at www.mgma.org.

Q. How long should medical records be stored?
A. Some states have specific guidelines that can be checked through your local board of medicine. The Doctors Company recommends the following:

• Adult patients: 10 years from the date the patient was last seen.
• Minor patients: 28 years from the birth of the minor patient.
• Deceased patients: One to five years (varies by state).

Q. What should I do if I learn that a patient has stolen my prescription pad or altered his or her prescription?
A. We recommend that you:

• Confront the patient. Make sure that you do this in an environment that is safe for you, your staff, and your other patients.
• Report the offense to your local police department.
• Alert the pharmacist.
• Review your office procedure for storing prescription pads.

Q. If I call the Department of Patient Safety, is it the same as reporting a potential claim?
A. No. The Patient Safety Department is a service available to you as a policyholder for purposes of providing advice and resource information. The regional patient safety/risk manager may suggest that you call the Claims Department to discuss an event. The claims representative will then discuss your options and the appropriate reporting procedures. It is important to remember that calling your regional patient safety/risk manager does not trigger your coverage with The Doctors Company. Your coverage is triggered by your written communication with the Claims Department. For more information on reporting a claim, visit
www.thedoctors.com/claims.

Q. What is my responsibility to a patient who fails to follow my recommendation for a diagnostic test?
A. If you order, recommend, or schedule a test, you are responsible for all follow-through—including ensuring that the results are received, reviewed, and reported back to the patient and that the results are documented in the medical record. Your office should have a tracking/recall system in place to ensure that test results are not lost or overlooked.

If you have made a recommendation for a test and the patient chooses to schedule it later, the patient bears some but not all of the responsibility for follow-through. In situations where follow-up is critical to the patient, your office staff should schedule the appointment for the patient. If a patient has a history of being noncompliant with your recommendations, documenting your efforts is important.

Q. As a male provider, should I have a female chaperone present when examining female patients?
A. Yes. Additionally, anytime there may be an awkward or uncomfortable situation with either gender, it’s a good idea for a chaperone of the same gender as the patient to be present during the examination.

Q. What measures should I take to ensure that my practice is covered when I hand off call to another physician?
A. There should be a clear directive for after-hours calls. For example, “If this is an emergency, hang up and call 911 or go to your nearest emergency department.” For nonemergency calls, there should be an answering service or a method for contacting the physician on call in your absence.

• Note that the on-call physician should be the same specialty as you.
• Ensure that the on-call physician has current medical malpractice insurance.
• Debrief the on-call physician before and after you hand off the call responsibility.

Q. Can I dismiss a patient from my practice at will?
A. Discharging a patient from a practice should be evaluated on a case-by-case basis. You should not adopt a blanket policy, as there are criteria to be met or evaluated. Please contact us to receive an information packet containing sample letters and criteria.

Q. If I refund or adjust a bill for a dissatisfied patient, is it considered an admission of liability?
A. Not necessarily, but each situation should be evaluated on its own merit. There are factors to consider from a professional liability and compliance standpoint. In some situations, it may be viewed as a “courtesy” gesture and may be a positive factor in the defense of a claim. Other situations may warrant the use of a Release of Claims form.

Q. Is it a good idea to keep personal notes for the purpose of refreshing my memory in the event of an adverse outcome?
A. Health care providers sometimes think that memorializing events shortly after they occur may be helpful (and perhaps even cathartic), particularly when a medical error or adverse outcome has occurred. However, these notes may be “discoverable” by the plaintiff’s counsel in the event of a lawsuit, and therefore, maintaining this type of documentation is discouraged.

Q. Is it okay for a nurse or other employee to witness the patient’s informed consent and make sure that the patient signs the form?
A. Once the physician has met his or her duty in the informed-consent process (i.e., having discussed with a patient the proposed procedure, including risks, benefits, and alternative treatment), a nurse or other delegate may obtain the patient’s signature on the form. If signing as a witness, the policy should clearly describe what the witness is “certifying.” However, before doing so, the patient should always be asked if he or she understands everything or has any questions. If there is any level of uncertainty expressed by the patient or his or her representative, the physician should address it directly.

Q. As a plastic surgeon, should I refuse to perform cosmetic surgery on a patient with whom I am not comfortable?
A. When asked to perform elective surgery on a patient with whom you are uncomfortable, consider declining the patient. This news should be communicated in a manner that does not offend or anger the patient. It is certainly a better option than proceeding, only to have a dissatisfied or unrealistic postsurgical patient allege abandonment of care. You may contact the Patient Safety Department for guidelines on patient selection.

Q. Do patients have to sign a release for their own medical records?
A. Yes, absent a subpoena, any request for medical records requires a properly signed and dated HIPAA release form from the patient or from the appointed surrogate decision maker. In the case of a deceased patient, there should be evidence of the appointment of a surrogate.

J4263 6/06

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