All health care professionals including advanced practice clinicians (nurse practitioners and physician assistants) want to prevent any potential legal actions related to the excellent care they provide.
Let me first start off by saying, I am not an attorney and I don’t play one in real life, on TV or on the internet. I had never even been in a real courtroom until recently. However, back in 2006 became involved in an investigation of another health care professional that has only recently gone to trial, and have spent a good amount of time researching the topic for past and future presentations. Thus, I’d like to share just a few tips that you can take to protect yourself as you continue to provide excellent care to your patients.
First and foremost, pay attention to your documentation! Make sure it tells the story, discusses your findings, your assessment and your plan. Whoever is reading the note, should be able to understand how you got to your proposed plan AND be able to pick up where you left off, making any necessary adjustments.
Don’t assume that someone can read your mind and don’t assume you will remember 1, 6 or 52 weeks later. While not everyone is able to complete each and every chart in the room before the patient leaves, make serious attempts at getting your charting done as soon as it’s feasible. Memory fades over time. Need a refresher on documentation? Here is a primer on documentation published by CMS-(The Centers for Medicare and Medicare Services) Search their site for “Documentation Guidelines for Evaluation and Management (E/M) Services”
Coding and Billing:
You may not be doing the billing in your office, but chances are you are responsible for coding the level of the visit. It’s your responsibility to be aware of the requirements for level of care regardless if your CPT code reflects the work and acuity of the patient, or the time spent. Make sure you have documented accordingly. If you need to brush up on your E&M coding skills, you can get some great free education at http://www.emuniversity.com. Coding the wrong level of service, or even “incident to” inappropriately, can land you in hot water.
Believe it or not, medication errors continue to be quite common. In fact, according to the 2009 NP claims study*, more than 80% of medication errors are prescription-related and 1/3 of those involved prescribing the WRONG medication.
Make sure you check and double check your prescriptions for spelling, dose, indication, side effects and contraindications. If you are using any of the electronic prescribing tools available, it should help, but they are not foolproof. Take advantage of the various tools you can use in the room with you including those on your PDA or smartphone. Epocrates, my favorite is only one of the various tools available.
If you have legal concerns, it’s always best to check with an attorney who is familiar with health care, advanced practice issues, and is in your state. Make sure you have appropriate liability coverage. All healthcare providers today have a tremendous responsibility to do the best they can do, often under less than ideal situations. Despite this, we continue to do our best to provide the best level of care we can for our patients and clients. These suggestions can help protect you (and your patients) even years into the future.
*2209 NP Claims Study can be found at http://www.nso.com Once there, search for the following search terms to see the report: “2009 NP claims study”