Trust Risk Management Services, Inc. insures over one hundred types of Allied Health Professionals including Marriage and Family Therapists, Licensed Professional Counselors, Behavior Analysts, Social Workers and other Allied Health Professionals not related to behavioral health including Dietitians, Dental Hygienists, Physical Therapists and many others. As an Allied Health Professional, you may work in a variety of settings including hospitals, outpatient centers, clinics and small or solo group practices (“employer”). Despite all these differences, there are some basic risk management principles to keep in mind when you are treating patients. The goal is to provide care to your patients and also to minimize your risk of liability should something negative occur. Some of these risk management principles include:
Be Aware of Your Profession’s Ethics Code. Your profession’s ethics code may provide guidance on a variety of topics. If you have questions or concerns, consider checking the ethic’s code to determine if there is any insight into the issue. Also, you may be able to find additional information on your profession’s national, regional or state website.
Documentation. No matter which type of practice you are in, you probably have heard the saying, “if it wasn’t documented, it wasn’t done.” If you ever are faced with a lawsuit or disciplinary matter, documentation may be critical for an attorney defending you. Additionally, you may receive a request for the patient’s records or a request to testify at trial, and even if your care is not being questioned, records may be important in these types of situations as well. You may document in an electronic health record or possibly in a paper record, depending on your type of practice and what your employer uses. Documentation provides others who also treat the patient with effective communication, supports billing and provides support for the quality of care provided. Timely documentation is also important. You may have back-to-back scheduling and may not be able to document right away after seeing the patient. However, try to document as close to the time of the patient contact as possible.
Documentation Policies. If your employer has a policy on documentation, make sure you are aware of this policy. Standardized policies are typically in place to ensure compliance among the team and can ensure that best documentation practices are followed. Ask if your employer has such a policy.
Missed Appointments. If a patient misses an appointment, document this as well.
What may need to be documented. This will vary widely depending upon what your practice is. In general, document information regarding:
- Treatment and diagnosis
- Assessment of patient in each session
- Recommendations/referrals
- Medications, if applicable
- Informed Consent
- Objective documentation of compliance or non-compliance with treatment
- If any boundary issues arise
- If you are ending treatment with the patient for whatever reason, this should be thoroughly documented
- Documentation reflecting any telephone call or text communication. It is recommended that you save a screen shot of the text communication for your record.
- Emails
Informed Consent. It is important to make sure when treating a patient that you have permission to do so and from the party who can provide authorization. Depending on your practice, you may treat minors or those who lack capacity to make informed decisions such as individuals with dementia, etc. For example, a grandmother may bring a patient in to be seen, but she may not have legal authority to complete paperwork relating to treatment.
Patient Interaction. In general, patients often will likely not file complaints or lawsuits against providers who maintain professional relationships, when they feel they are listened to, their concerns are addressed or if follow up in addressing their needs occurs. If they feel you are rude, dismissive, or do not address their concerns, then they may be more inclined to file a complaint against you. It is always important to maintain professionalism.
Boundary crossings/violations. It was mentioned above to be aware of your profession’s ethics code. It is important to be aware of what is an appropriate interaction with patients/prior patients. This can include types of relationships such as business relationships or social relationships.
Patient Privacy. Be mindful of your state rules and rules under HIPAA for privacy and confidentiality and ensure they are adhered to.
Record Keeping/Retention. States have differing rules on how long patient records need to be kept. The timeframe may also vary depending upon whether the patient is a minor or an adult. Your employer should be aware of the requirements and should set policies that comply with the rules. However, it is important for you to also be aware of the rules. Additionally, should you leave your employer, it is important to know if they will maintain the patient’s records and for how long.
State Laws and Regulations. Each state has its own set of laws and regulations. You should know what applies to you, and if you should need a regulation explained/interpreted, you might consider reaching out to an attorney for advice.
Author: Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM, Healthcare Practice and Risk Management Innovation Officer
NOTE: This information is provided as a risk management resource and is not legal advice or an individualized personal consultation. At the time this resource was prepared, all information was as current and accurate as possible; however, regulations, laws, or prevailing professional practice standards may have changed since the posting or recording of this resource. Accordingly, it is your responsibility to confirm whether regulatory or legal issues that are relevant to you have since been updated and/or to consult with your professional advisors or legal counsel for timely guidance specific to your situation. As with all professional use of material, please explicitly cite The Trust as the source if you reproduce or distribute any portion of these resources. Reproduction or distribution of this resource without the express written permission of Trust Risk Management Services, Inc. is strictly prohibited.