What else do you need to know about the patient besides the presenting complaint and the patient’s description of his/her concerns? Certainly, you will want to review the patient’s medical history – however briefly – to determine if there are issues or conditions present that may impact your decisions used to formulate your proposed treatment.
Referrals and consults may not be for you as routine as for a medical or dental clinician, but the need may arise from time to time (such as for a neurological consult). Consider the following:
· Do you have a standardized procedure for making such a referral?
· Do you make the referral in writing?
· Do you have some kind of acuity system for referrals, such as “get this done before the end of today,” or “see this specialist within the next two days,” or “try to get an appointment within the next ten days”?
For those high acuity referrals, do you follow up with the patient via a phone call to determine whether or not the patient has followed up as instructed and do you document these phone calls (both attempted and completed calls) in the patient record?
The patient record should be organized in such a way as to record sequentially each patient encounter noting the date and time of each appointment or phone call. Be sure to do this routinely since New Jersey regulations make it a requirement.
With regard to entering a description of care or services rendered in the patient’s record, does anyone in your practice provide any service to the patient? If so, be certain to enter the name of licensee providing treatment as well.
The principle of Informed Consent continues to elicit comment and questions, while stimulating lively debate from all corners of the healthcare universe. For the sake of clarity, we look at informed consent as a two-fold issue: There is the discussion and there is the form.
The discussion: Do you make an entry that the educational discussion took place with your patient? This entry captures and memorializes the essence of the discussion to include RBA (risks, benefits, alternatives). Furthermore, the entry recognizes patient questions and reservations. Does the informed consent note in the patient record reflect that the patient has received information that has satisfied all concerns and that there are no further questions regarding the proposed treatment?
The form: Do you use a “consent to treat” form that documents patient agreement with the proposed treatment and his/her authorization to proceed with the treatment plan or proposed care?
There are other components of documentation that may not be a part of every patient encounter, but components that you want to remember as the situations arise. For instance, do you make a note of significant changes in your patient’s condition or significant changes in your care plan for that patient due to a recent event or some other factor affecting the patient since your first assessment? For this reason, we suggest making a periodic notation of patient status “regardless of whether significant changes have occurred.”
We will conclude with a question we at Princeton get all the time: “How long do I need to retain records? I’m running out of storage space.” Maintaining records (including films and all other diagnostic findings) is required for seven (7) years from the date of the last entry or patient encounter (including phone calls). For minors, maintain your records for seven years from the date of the last entry or seven years from the date of majority, which ever is later.
As always, we are here to assist you with your risk management and patient safety endeavors. We welcome any and all opportunities to speak with you about questions or concerns you have. Contact us at 1-800-RX 4-Risk.