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MANAGING YOUR BACK OFFICE TO REDUCE THE RISK OF LAWSUITS
by Waldene Drake, RN, MBA
Vice President, Risk Management
and
Dan Groszkruger, JD, MPH
Consulting Editor

A physician’s “back office” represents an important, but often under-rated, source of patient dissatisfaction and potential liability problems. No matter how good a job is done with patients upon reception in the front office, all positive first impressions can be erased if the same level of respect, professionalism and caring is missing from the back office.

This article highlights back office operations which pose significant risks and offers some practical advice on how to reduce these risks. This topic is one of four subject areas (Front Office; Back Office; Medical Records; Education & Training) addressed in CAP-MPT’s new publication, “Risk Management Self-Assessment Kit: Reducing Liability Risk in Your Medical Office.” ¹

Efficiency: Time to spend with patients is increasingly scarce. Efficiency may be improved while you also reduce liability in the following ways:

• Use medication lists and problem lists in medical records. Even the best physician cannot remember all of the patient’s diagnoses and medications. Significant medical information may be overlooked if not easily accessible or prominently displayed.
• Thoroughly document patient-physician discussions on the risks and benefits of recommended treatments and regimes. Informed consent, or informed refusal, takes place here— between the patient and his physician. By law, this discussion may not be delegated to anyone other than a physician. It should be contemporaneously documented in the record, whether or not a consent form is also later signed.
• Use SOAP format (Subjective and Objective information, Assessment, and Plan) or another structured outline for content of progress notes to ensure systematic recording of information. Exam checklists and flow sheets also help ensure that all essential elements of the exam were documented. All empty spaces in a checklist, however, should be completed, even if only with an “N/A” (not applicable) notation. Such forms also help remind the physician when recommended periodic exams are due.

• If patient follow-up is necessary, staff should follow procedures and take steps to make sure the patient understands the need to return. Some offices have the patient commit to a return appointment before leaving. Then, if the patient fails to keep the appointment, a follow-up call is automatically triggered.
• Track your “high-risk” patients. Whether by manual log, a tickler file, or on the computer, a protocol is necessary to assure these patients are not lost to follow-up. Each practice will need to identify the specific conditions or abnormal diagnostic results they wish to track. For instance, in a primary care practice, patients with family histories of breast, colon, or prostate cancer may be targeted and their mammograms, colonoscopies, and PSA results closely tracked.
• Eliminate the “No news is good news” method of reporting test results back to the patient. If, for whatever reason, the results are lost, the patient may wrongly assume they were normal, a potentially dangerous assumption. Logs of all laboratory tests ordered should be maintained and used to track results.
• File a copy of the patient’s prescriptions, or the order for the medication (including dose, route, frequency, and duration) in the medical record. This may be valuable later as evidence of proper prescribing.

• Use a triage system for telephone messages to ensure prompt physician attention, when necessary. When the physician returns the call to the patient, document the discussion and instructions to the patient.
• Assure that no test abnormality is missed. All test reports should be reviewed by a physician before the results, and the record, are filed. Make sure all staff understand this concept, including those that open the mail, those that watch the fax machine, filing clerks, and any temporary employees. There is little defense if, months after the fact, abnormal test results are found. • Make sure the physician, or his designee, communicates test results to the patient and notes the communication, and patient instructions for follow-up, in the medical record.
• The physician, or an advanced practice professional, should approve all prescription refill requests. If the physician chooses to delegate this important activity, it should be assigned only to specific staff members who are given specific refill protocols. For example, the physician may permit Lasix to be refilled monthly for one year without an exam while a request for nitroglycerin may not be refilled at all without physician approval.
• List all prescription refills in a prominent place in the medical record. Such a list promotes early recognition of excessive, or inappropriate, refill requests.

• Adopt an office procedure for “Patient Down” including how to summon help and what to do before paramedics arrive. Local Emergency Medical Services (EMS) response may be the best plan for most practices.
• Post telephone numbers and emergency contact information for local fire, police, and EMS near all office telephones.
• Train and regularly re-certify staff in basic first aid and CPR (if appropriate) to render aid until professional help arrives.
• If you maintain a crash cart, develop office policies that ensure that personnel are properly trained, that medications are current, and that equipment is properly maintained. Depleted supplies and outdated medications are a liability and may contribute to patient injury.
• Maintain all records of staff training and in-service classes about use of crash carts, checks of equipment & supplies, and equipment maintenance.
• If children are seen in the office, make sure the crash cart includes specialized pediatric-sized equipment and medication in pediatric strengths.