TRACER FINDINGS RECORDING FORM
SAMPLE
Physician Practice Group
Risk Assessment
Risk Management Objectives
1. To introduce physicians, office managers and staff to a systematic
review to identify strengths and weaknesses in a physician practice.
2. To identify practices that place physician offices at risk of liability,
recognition of patient safety issues that could lead to patient harm,
to help provide safer and better care, and limit risk of medical
malpractice.
3. To promote patient safety commitment among physicians and staff.
4. To collect baseline information which will allow comparison of
physician practices for benchmarking purposes.
5. To create baseline comparisons so that practices are able to monitor
themselves following implementation of improvement strategies.
6. To reduce the likelihood of system breakdowns and errors in patient care.
Risk Assessment Plan
The Risk Assessment Tool for physician offices is a tool to help identify strengths and weaknesses in a physician practice. The survey is organized into key areas. It allows staff within the various settings to provide input by completing the survey. Surveys are completed over a two to three week time frame. All self-assessments will be followed up by a Clinical Risk Specialist who will do an on-site survey.
Assessment reports will be generated within 3 weeks of completion. The report will include strengths and identify opportunities for improvement. The assessment will help to identify and prioritize areas most in need of improvement and risk reduction.
There is no scoring system. The options for responding to the statements are Always/ Yes, Sometimes, Never/NO, and NA. The ideal response to each statement is Always /Yes or N/A. Any other response indicates an area of potential risk in the practice and should be addressed and resolved.
The Risk Assessment Tool includes the Enterprise or whole system approach. The Risk Management team will focus on Clinical Issues and consult additional departments as needed for assistance/ follow up. (Such as Infection Control Issues or Environment of Care Issues). Clinical areas (high-lighted in yellow) will be the primary focus of the Clinical Risk Specialists.
After an assessment, the Clinical Risk Specialist will analyze the findings and develop the Assessment Report. The report will be generated within 3 weeks of completion. The report will include the strengths and identify opportunities for improvement. The assessment will help to identify and prioritize areas most in need of improvement and risk reduction. A copy of this report will be provided to the following:
Following the risk assessment, the Practice Manager should review the results with physician leaders. Together they can define goals, develop and implement strategies to meet the goals. Areas for risk reduction and safety can be prioritized and goals made into an action plan.
The Practice Manager will return the action plan to the Clinical Risk Specialist within 3 weeks of receiving the assessment report.
1. New acquisitions will be audited as follows to establish an initial baseline, to ensure patient safety and to decrease risks.
a. Within one month of purchase
b. 6 Month Audit
c. Annual Risk Assessment
2. Established practices will be audited as follows:
a. Initially by completion of the self-assessment utilizing the Risk Assessment Tool.
b. Verification of self-assessment will be completed by a Clinical Risk Specialist completing
an on-site evaluation.
c. Annual Risk Assessment
Table of Contents
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Risk Assessment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Practice Assessment Checklists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 22
Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Advance Directives/ Patient’s Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Cultural Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Medication Use and Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 9 Physician Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Procedure Consents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Respiratory Isolation Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 - 11
Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Credentialing/Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 - 12
Office Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 - 13
Telephone Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 - 15
Health Information Management / Documentation . . . . . . . . . . . . . . . . . . . . . . . 14 - 16 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 - 18
Communication and Teamwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 - 19
Americans with Disability Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 - 20
Clinical Laboratory Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Risk Management / Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 – 20
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 - 22
Corrective Action Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
TRACER FINDINGS RECORDING FORM
Date: __________ Office Reviewed: ___________________________ Reviewer(s): _____________________________
|Topic |Findi|Always/ Yes |Sometime |Never/ NO |Practice | |
| |ngs: | | | |Action Plan | |
| |Check| | | | | |
| |ed | | | | | |
| |Items| | | | | |
| |Indic| | | | | |
| |ate | | | | | |
| |Compl| | | | | |
| |iance| | | | | |
| | |Type and Number of Staff | | | | |
| | |Employed: | | | | |
| | |Registered Nurses ____ | | | | |
| | |LPN/LVN _________ | | | | |
| | |Medical Assistants _____ | | | | |
| | |Nurse Aides__________ | | | | |
| | |Receptionists ________ | | | | |
| | |There are current job | | | | |
| | |descriptions for all positions. | | | | |
| | |There is an orientation process | | | | |
| | |for new staff members. | | | | |
| | |Staff members do not perform | | | | |
| | |tasks beyond their scope of | | | | |
| | |licensure, certification or | | | | |
| | |training. | | | | |
|Advance Directives, Patient Rights | |Questions about advance | | | | |
| | |directives are completed during | | | | |
| | |the initial screening process | | | | |
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| | |If the patient has an advance | | | | |
| | |directive, there is a current | | | | |
| | |copy on the chart, with the | | | | |
| | |health care agent name and | | | | |
| | |contact information listed | | | | |
| | |If there is an advance directive | | | | |
| | |but no copy on the chart, the | | | | |
| | |patient has been instructed to | | | | |
| | |provide one | | | | |
| | |Charts and patient-sensitive | | | | |
| | |information is stored and kept in| | | | |
| | |a manner that protects the | | | | |
| | |patient’s privacy | | | | |
| | |Patients in the waiting area | | | | |
| | |cannot overhear telephone | | | | |
| | |conversations | | | | |
| | |If there are open areas that | | | | |
| | |cannot be structurally changed, | | | | |
| | |there is an area where sensitive | | | | |
| | |and confidential issues can be | | | | |
| | |discussed so that others cannot | | | | |
| | |hear. (Use of white noise | | | | |
| | |machines? Yes or NO | | | | |
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|Advanced Directives and Patient | | | | | | |
|Rights | | | | | | |
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| | |Abuse/neglect screening completed| | | | |
|Cultural Competency | |Preferred language in which to | | | | |
| | |discuss medical information is | | | | |
| | |documented in the record, if | | | | |
| | |applicable. | | | | |
| | |Language Line use is documented | | | | |
| | |w/ operator number. | | | | |
|Medication Use and Safety | |Current list of medications is | | | | |
| | |documented in the record, | | | | |
| | |including over-the-counter and | | | | |
| | |herbal supplements. List should | | | | |
| | |include medication dose and | | | | |
| | |frequency. | | | | |
| | |Medication list is updated each | | | | |
| | |office visit. | | | | |
| | |Allergies are listed and | | | | |
| | |displayed prominently; updated as| | | | |
| | |necessary. | | | | |
| | |Immunization status is documented| | | | |
| | |Medications are prepared in a | | | | |
| | |clean area. | | | | |
| | |Vaccine administration is | | | | |
| | |documented including date, dose, | | | | |
| | |expiration date, manufacturer and| | | | |
| | |lot number. | | | | |
| | |Vaccine Information Statement | | | | |
| | |given to patient (most recent | | | | |
| | |date) | | | | |
| | |Vaccines are either entered into | | | | |
| | |vaccine log or, if electronically| | | | |
| | |documented, history of same may | | | | |
| | |be accessed electronically. | | | | |
| | |If samples are held in the | | | | |
| | |offices: | | | | |
| | | Is there a drug sample control| | | | |
| | |program that includes inventory, | | | | |
| | |monthly checks of expiration | | | | |
| | |dates and a recall system? | | | | |
| | | Sample tracking logs are | | | | |
| | |utilized when samples are | | | | |
| | |dispensed. | | | | |
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|Medication Safety and Use | | | | | | |
| | | Samples are dispensed | | | | |
| | |directly by the physician, or, if| | | | |
| | |dispensed by the MA, correct | | | | |
| | |patient, drug, dose, route and | | | | |
| | |frequency are verified by the | | | | |
| | |physician prior to handing to | | | | |
| | |patient. | | | | |
| | | Sample closet is secured to | | | | |
| | |prevent diversion of medication | | | | |
| | |Stocked medication is stored per | | | | |
| | |manufacturer’s guidelines, | | | | |
| | |including refrigerated/frozen | | | | |
| | |vaccines. | | | | |
| | |Medication refrigerator temps are| | | | |
| | |checked at least daily; if out of| | | | |
| | |range temps are documented, | | | | |
| | |appropriate corrective action is | | | | |
| | |undertaken, documented and | | | | |
| | |follow-up temp is done. | | | | |
| | |There is a monitoring process in | | | | |
| | |place so that if the temperature | | | | |
| | |of the med refrigerator went out | | | | |
| | |of range off-hours, the staff | | | | |
| | |would be aware of it upon return | | | | |
| | |to the office. | | | | |
| | |If the med refrigerator is found | | | | |
| | |to be out of range, the staff | | | | |
| | |know what to do about it. | | | | |
| | |Medications - only - are stored | | | | |
| | |in med refrigerators (no | | | | |
| | |chemicals, oral contrast, lab | | | | |
| | |reagents, food, etc.) | | | | |
| | |Stocked medication including | | | | |
| | |biological and samples, | | | | |
| | |prescription pads and syringes | | | | |
| | |are stored in a secure area; | | | | |
| | |inventoried, and controlled? | | | | |
| | |should not have unsecured meds in| | | | |
| | |patient rooms | | | | |
| | |Process for administering | | | | |
| | |medications includes proper | | | | |
| | |patient identification and drug | | | | |
| | |orders verified before | | | | |
| | |administration of medications in | | | | |
| | |the office and follows law and | | | | |
| | |regulations for MA | | | | |
| | |administration? | | | | |
| | |Single dose vials are used for | | | | |
| | |one patient only and discarded | | | | |
| | |after one use (CDC guidelines on | | | | |
| | |Safe Injection practices are | | | | |
| | |followed.) | | | | |
| | |Multi-dose vials are dated with a| | | | |
| | |28 day expiration date, unless | | | | |
| | |manufacturer’s expiration date | | | | |
| | |precedes that date. | | | | |
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| | |Medications from multi-dose vials| | | | |
| | |are drawn up with a clean needle | | | | |
| | |and syringe each time the stopper| | | | |
| | |is pierced. If the same needle | | | | |
| | |or the same syringe is used, the | | | | |
| | |vial is considered to be single | | | | |
| | |patient use and is discarded | | | | |
| | |after the patient leaves. | | | | |
|Medication and Safety Use | |Meds drawn up from a multi-dose | | | | |
| | |vial in a non-patient care area | | | | |
| | |should be labeled with the drug | | | | |
| | |name, dose/concentration unless | | | | |
| | |taken directly to the patient and| | | | |
| | |injected. | | | | |
| | |Does the physician review every | | | | |
| | |request for prescription refills | | | | |
| | |personally? | | | | |
| | |Is patient information readily | | | | |
| | |available to providers when | | | | |
| | |ordering medication/writing | | | | |
| | |prescriptions? | | | | |
| | |Is a copy of all medication | | | | |
| | |orders and prescriptions | | | | |
| | |maintained in the patient’s | | | | |
| | |office record? | | | | |
| | |Are all medications that are | | | | |
| | |dispensed from the office | | | | |
| | |properly labeled? ( Check | | | | |
| | |competency skills checklist for | | | | |
| | |medical assistants for | | | | |
| | |administering medications) | | | | |
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| | |Are medications and biological | | | | |
| | |prescribed and administered only | | | | |
| | |by qualified providers and by | | | | |
| | |staff within their scope of | | | | |
| | |practice | | | | |
| | |Do policies prohibit the use of | | | | |
| | |pre-signed and /or postdated | | | | |
| | |prescription forms? | | | | |
| | |Are there protocols for handling | | | | |
| | |patient requests for prescription| | | | |
| | |renewals? (Is there protocol | | | | |
| | |listing of what can and cannot be| | | | |
| | |done and by whom) | | | | |
| | |Is there a policy that requires a| | | | |
| | |“read back” of the complete order| | | | |
| | |by the person taking verbal or | | | | |
| | |telephone medication orders to | | | | |
| | |confirm that they are correct? | | | | |
| | |Is a complete drug history – | | | | |
| | |including prescription and | | | | |
| | |over-the-counter medications, | | | | |
| | |herbal products/nutritional | | | | |
| | |supplements, and illicit drugs – | | | | |
| | |obtained and documented at the | | | | |
| | |initial patient encounter and | | | | |
| | |updated periodically? | | | | |
| | |Are two patient identifiers | | | | |
|Medication and Safety Use | |confirmed and drug orders | | | | |
| | |verified before administration of| | | | |
| | |medications in the office? | | | | |
| | |Is a current medication list | | | | |
| | |maintained in the records of all | | | | |
| | |patients on drug therapy? | | | | |
| | |Is there a process for handling | | | | |
| | |drug recalls? | | | | |
| | |If a crash cart or emergency | | | | |
| | |tackle box with medications | | | | |
| | |exists in the office, the box is | | | | |
| | |checked monthly for expired | | | | |
| | |medications. | | | | |
|Physician Progress Notes | |Completed with office visits | | | | |
| | |Legible | | | | |
| | |Each entry is dated and signed | | | | |
| | |Is there a protocol for physician| | | | |
| | |referral on specific abnormal | | | | |
| | |findings? | | | | |
| | |Please specify. | | | | |
|Procedure Consents | |Informed consent obtained by | | | | |
| | |physician; risks, benefits, | | | | |
| | |alternatives in progress notes or| | | | |
| | |physician signature on all | | | | |
| | |invasive procedures or treatments| | | | |
| | |(surgical/ special procedures) | | | | |
| | |permit | | | | |
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| | |If invasive procedures are | | | | |
| | |performed in the office, are | | | | |
| | |discharge instructions provided | | | | |
| | |to the patient/ family in | | | | |
| | |writing? | | | | |
| | |Is a copy placed in their chart? | | | | |
| | |Any conscious sedation ever | | | | |
| | |utilized? If so, who is using | | | | |
| | |it? Who is monitoring? What are | | | | |
| | |they monitoring? | | | | |
| | |Are informed-consent discussions | | | | |
| | |documented by the physician in | | | | |
| | |the patient’s office medical | | | | |
| | |record? | | | | |
| | |Is patient consent obtained and | | | | |
| | |documented for the taking of | | | | |
| | |photographs, videotapes, or other| | | | |
| | |individually identifiable images | | | | |
| | |of patients? | | | | |
| | |Procedural or surgical consents | | | | |
| | |are dated and timed | | | | |
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|Respiratory-Specific Isolation Practice | |Suspected flu or Ebola patients | | | | |
|( n/a | |are placed into private room with| | | | |
| | |door closed and patient mask | | | | |
| | |applied | | | | |
| | |Suspected TB or Ebola patients | | | | |
| | |are placed into private room with| | | | |
| | |door closed and patient mask | | | | |
| | |applied | | | | |
| | |Patients with respiratory | | | | |
| | |symptoms should be offered a mask| | | | |
| | |if it is expected that they will | | | | |
| | |be in the waiting room for any | | | | |
| | |period of time. | | | | |
| | |Have selected personnel been | | | | |
| | |fit-tested for use of a NIOSH | | | | |
| | |approved TB respirator mask ( | | | | |
| | |N-95, HEPA)? | | | | |
|Safety | |Specimens are labeled in the | | | | |
| | |presence of the patient with at | | | | |
| | |least two identifiers (name and | | | | |
| | |DOB), date, time and signature of| | | | |
| | |staff | | | | |
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|Safety | | | | | | |
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| | |Are children seen in the office? | | | | |
| | |Do you have appropriate equipment| | | | |
| | |for children (e.g., BP cuffs, | | | | |
| | |etc)? | | | | |
| | |Are bariatric patients seen in | | | | |
| | |the office? | | | | |
| | |Do you have appropriate equipment| | | | |
| | |for bariatric patients (e.g. BP | | | | |
| | |cuffs, wheel chairs, etc)? | | | | |
| | |Are mock emergency drills | | | | |
| | |conducted periodically, and is | | | | |
| | |the adequacy of the response | | | | |
| | |evaluated | | | | |
| | |Are procedures in place to | | | | |
| | |identify and handle patients who | | | | |
| | |may be pregnant? | | | | |
| | |Are patients identified and the | | | | |
| | |site of the procedure verified | | | | |
| | |before the start of any procedure| | | | |
| | |Do policies provide for the use | | | | |
| | |of a chaperone during intimate | | | | |
| | |patient examinations? (Male: | | | | |
| | |Female and same sex) | | | | |
| | |Are patients assessed and | | | | |
| | |monitored before, during, and | | | | |
| | |after office procedures according| | | | |
| | |to medical need and standard of | | | | |
| | |practice? | | | | |
| | |Is the use of sedation or any | | | | |
| | |other nonlocal anesthesia | | | | |
| | |governed by | | | | |
| | |Policies and procedures | | | | |
| | |Is there a policy and procedure | | | | |
| | |for handling emergencies that | | | | |
| | |arise in the office? | | | | |
| | |All equipment is functioning | | | | |
| | |properly and staff is properly | | | | |
| | |instructed in its use. | | | | |
| | |Does all equipment at the | | | | |
| | |physician practice site undergo | | | | |
| | |periodic inspection, testing, and| | | | |
| | |preventive maintenance? | | | | |
| | |Are inspection and preventive | | | | |
| | |maintenance procedures | | | | |
| | |documented? | | | | |
| | |Are office personnel instructed | | | | |
| | |on what to do if a device | | | | |
| | |malfunctions? | | | | |
| | |Do all office-based users of | | | | |
| | |medical devices receive adequate | | | | |
| | |training before use on patients? | | | | |
| | |Is the above training documented?| | | | |
|Credentialing/Competency | |Is there a formal credentialing | | | | |
| | |and periodic re-credentialing | | | | |
| | |process For all providers (e.g. | | | | |
| | |physicians or other licensed | | | | |
| | |independent or dependent | | | | |
| | |practitioners) associated with | | | | |
| | |the office practice? | | | | |
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|Credentialing and Competency | | | | | | |
| | |Is there a mechanism for | | | | |
| | |periodically reassessing each | | | | |
| | |provider’s and each employee’s | | | | |
| | |clinical competence? | | | | |
| | |Is this evaluation documented? | | | | |
| | |Are there current, written | | | | |
| | |collaborative practice agreements| | | | |
| | |for midlevel providers (e.g. | | | | |
| | |physician assistants, nurse | | | | |
| | |practitioners) as applicable? | | | | |
| | |Do unlicensed assistive personnel| | | | |
| | |(e.g. medical office assistants) | | | | |
| | |function under the supervision of| | | | |
| | |a licensed healthcare | | | | |
| | |professional? | | | | |
| | |Are there scheduled quality | | | | |
| | |review meetings with staff to | | | | |
| | |review cases? | | | | |
| | |Is there a formal office | | | | |
| | |orientation program with periodic| | | | |
| | |(annual, at minimum) educational | | | | |
| | |updates for all providers and | | | | |
| | |staff? | | | | |
| | |Are all clinical staff certified | | | | |
| | |with cardiopulmonary | | | | |
| | |resuscitation (CPR) | | | | |
| | |and trained in emergency-response| | | | |
| | |procedures? | | | | |
| | |Are all office providers and | | | | |
| | |staff trained in the use of | | | | |
| | |office equipment during | | | | |
| | |orientation and on all new | | | | |
| | |devices before the devices are | | | | |
| | |placed into use?. | | | | |
|Office Procedures | | | | | | |
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|Office Procedures | | | | | | |
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| | |Does the practice use clinical | | | | |
| | |practice guidelines that are base| | | | |
| | |either on evidence from | | | | |
| | |recognized sources or on current | | | | |
| | |professional knowledge by | | | | |
| | |board-certified /eligible | | | | |
| | |practitioners? (If the physician | | | | |
| | |does not use the standard, does | | | | |
| | |he document why not – does he | | | | |
| | |give a rationale?) | | | | |
| | |Is there a policy regarding | | | | |
| | |missed appointments or | | | | |
| | |cancelations that includes | | | | |
| | |permanent documentation and | | | | |
| | |notification of the provider to | | | | |
| | |determine action on rescheduling?| | | | |
| | |Does the practice have a system | | | | |
| | |for triaging telephone calls? | | | | |
| | |Is the system based on physician | | | | |
| | |–approved protocols by | | | | |
| | |appropriate-level staff? | | | | |
| | |Lengthy voice mail, with various | | | | |
| | |options, is not used to screen | | | | |
| | |calls. It is easy to access a | | | | |
| | |person to answer a phone. In | | | | |
| | |other words there is a shortcut | | | | |
| | |to get a person on the phone. | | | | |
| | |Are callers allowed to speak | | | | |
| | |before they are put on hold? | | | | |
| | |If an automatic call distribution| | | | |
| | |system is used, does it include | | | | |
| | |an option for patients to speak | | | | |
| | |to someone in the event of a real| | | | |
| | |emergency? | | | | |
| | |Does the physician practice have | | | | |
| | |a written policy on telephone | | | | |
| | |advice protocols? (Is it posted | | | | |
| | |where people can see it?) | | | | |
| | |Is a system in place to monitor | | | | |
| | |staff compliance with the | | | | |
| | |protocols? | | | | |
| | |Do nurses and other staff who | | | | |
| | |give telephone advice have | | | | |
| | |specific training, experience and| | | | |
| | |documented competence in | | | | |
| | |telephone assessment techniques? | | | | |
| | |Is staff instructed to consult a | | | | |
| | |physician whenever they have | | | | |
| | |doubts about proper instructions | | | | |
| | |or advice? | | | | |
| | |Are physicians instructed to be | | | | |
| | |receptive to questions by office | | | | |
| | |staff regarding patient calls? | | | | |
| | |Is there a consistent procedure | | | | |
| | |for handling phone-in lab | | | | |
| | |reports? | | | | |
| | |Does this include a policy | | | | |
| | |addressing how to relay “panic | | | | |
| | |values” to the physician? | | | | |
| | |Is an answering service used | | | | |
| | |during off hours? | | | | |
| | |If no, can messages be retrieved | | | | |
| | |and addressed promptly at all | | | | |
| | |times? | | | | |
| | |If yes, are the service’s | | | | |
| | |policies and procedures for | | | | |
| | |answering physician office calls | | | | |
| | |regularly reviewed? | | | | |
| | |Is the caller immediately | | | | |
| | |informed that he or she is | | | | |
| | |dealing with an answering | | | | |
| | |service? | | | | |
| | |Does the service verify the | | | | |
| | |caller’s name and telephone | | | | |
| | |number? | | | | |
| | |Is the service provided with an | | | | |
| | |emergency procedure in case the | | | | |
| | |physician on call cannot be | | | | |
| | |reached? | | | | |
| | |Is there documentation in the | | | | |
| | |patient’s record of after hour | | | | |
| | |calls? | | | | |
| | |Are the test calls placed | | | | |
| | |periodically to assess the | | | | |
| | |performance of the answering | | | | |
| | |service? | | | | |
| | |Is dictation, transcription, and | | | | |
| | |filing of reports timely (e.g., | | | | |
| | |within 24 to 48 hours)? | | | | |
|Health Information Management / | |Are transcribed reports | | | | |
|Documentation | |authenticated by signature of the| | | | |
| | |responsible provider in a timely | | | | |
| | |manner (e.g., within 48 to 72 | | | | |
| | |hours)? | | | | |
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|Health Information | | | | | | |
|Management/ | | | | | | |
|Documentation | | | | | | |
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|Health Information Management/ | | | | | | |
|Documentation | | | | | | |
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| | |Are medical records readily | | | | |
| | |available to providers when | | | | |
| | |needed (e.g., when treating | | | | |
| | |patients in the office or over | | | | |
| | |the telephone)? | | | | |
| | |Is drug, food and other allergy | | | | |
| | |information documented | | | | |
| | |prominently in the paper or | | | | |
| | |electronic record? | | | | |
| | |Are all charting entries signed | | | | |
| | |and dated (by hand or | | | | |
| | |electronically)? | | | | |
| | |Is patient education regarding | | | | |
| | |health problems, medications and | | | | |
| | |plan of care documented? | | | | |
| | |If pain is part of the visit | | | | |
| | |complaint, pain score is | | | | |
| | |documented using 0-10 scale or | | | | |
| | |faces pain scale (in the case of | | | | |
| | |children) | | | | |
| | |Do patients receive written | | | | |
| | |instructions and information | | | | |
| | |regarding self-care and | | | | |
| | |follow-up? | | | | |
| | |Are instructions given to | | | | |
| | |patients documented in the | | | | |
| | |medical record? | | | | |
| | |Are written instructions provided| | | | |
| | |both in English and in languages | | | | |
| | |that represent the largest | | | | |
| | |limited-English speaking groups? | | | | |
| | |Is patient noncompliance and/or | | | | |
| | |informed refusal of recommended | | | | |
| | |treatment documented? | | | | |
| | |Are all telephone calls in which | | | | |
| | |a provider or staff member | | | | |
| | |provides treatment orders or | | | | |
| | |advice documented? | | | | |
| | |Does this documentation include: | | | | |
| | |Patient name? | | | | |
| | |Caller name (if different from | | | | |
| | |patient) | | | | |
| | |Physician name? | | | | |
| | |Date and time of call? | | | | |
| | |Reason for call (caller’s | | | | |
| | |statement as he/she relayed it)? | | | | |
| | |History of complaint, including | | | | |
| | |effect of any interventions taken| | | | |
| | |at home? | | | | |
| | |Follow – up, if applicable? | | | | |
| | |Advice given/treatment ordered? | | | | |
| | |Initials or signature of the | | | | |
| | |staff member taking the call? | | | | |
| | |Do you use off-site storage? (For| | | | |
| | |electronic records, do you have | | | | |
| | |backup systems?) | | | | |
| | |Are charts thinned? | | | | |
| | |If yes, by whom? ___________ | | | | |
| | | | | | | |
| | |What criteria are used? | | | | |
| | |_____________________ | | | | |
| | |Is a random selection of medical | | | | |
| | |records assessed periodically for| | | | |
| | |illegibility, inaccuracies, | | | | |
| | |omissions, alterations, or other | | | | |
| | |red flags indicative of poor | | | | |
| | |charting practices? | | | | |
| | |Does documentation of procedures | | | | |
| | |performed in the office include: | | | | |
| | |Patient identification and | | | | |
| | |verification of procedures / site| | | | |
| | |of procedure? | | | | |
| | |Patient assessment and | | | | |
| | |monitoring? | | | | |
| | |Description of the procedure? | | | | |
| | |Identification of any specimens | | | | |
| | |and their disposition? | | | | |
| | |Mediations administered? | | | | |
| | |Patient condition at discharge? | | | | |
| | |Has the practice standardized | | | | |
| | |abbreviation, acronyms, and | | | | |
| | |symbols for use throughout the | | | | |
| | |office and adopted a list of | | | | |
| | |abbreviations, acronyms, and | | | | |
| | |symbols not to use? | | | | |
| | |Is there a policy in place that | | | | |
| | |includes criteria for termination| | | | |
| | |of care/ discharge from the | | | | |
| | |practice? | | | | |
| | |Are records made available to the| | | | |
| | |new physician upon receipt of the| | | | |
| | |patient’s | | | | |
| | |Are policies and procedures in | | | | |
| | |place governing release of | | | | |
| | |medical records and imaging | | | | |
| | |films? | | | | |
| | |If original imaging films are | | | | |
| | |released, is there a tracking | | | | |
| | |system in place to retrieve them?| | | | |
| | |Do policies and procedures | | | | |
| | |address both state law and | | | | |
| | |requirements of the HIPAA privacy| | | | |
| | |rule for: | | | | |
| | |Requests for medical records from| | | | |
| | |patients, physicians and others? | | | | |
| | |Requests for medical records | | | | |
| | |containing sensitive information | | | | |
| | |(e.g., HIV status, psychiatric | | | | |
| | |information)? | | | | |
| | |Subpoenaed records and attorney | | | | |
| | |requests for records? | | | | |
| | |Are appropriate staff members | | | | |
| | |informed of these policies and | | | | |
| | |procedures? | | | | |
| | |Do you obtain written permission | | | | |
| | |for copies of records? | | | | |
| | |Are appropriate members of the | | | | |
| | |office staff aware of the medical| | | | |
| | |records release information | | | | |
| | |issues (e.g., drug and alcohol, | | | | |
| | |mental health, HIV) special | | | | |
| | |requirements? | | | | |
| | |Do you have policies and | | | | |
| | |procedures for physician/staff to| | | | |
| | |follow when asked to enter into | | | | |
| | |contracts, supervise students, | | | | |
| | |etc. | | | | |
| | |Is the patient notified in | | | | |
| | |writing by registered or | | | | |
| | |certified mail? | | | | |
| | |Does the termination letter | | | | |
| | |inform the patient about how to | | | | |
| | |obtain the services of another | | | | |
| | |physician and clearly state the | | | | |
| | |effective termination date? | | | | |
| | |Is there a mechanism in place to | | | | |
| | |monitor compliance with these | | | | |
| | |policies and procedures? | | | | |
|Confidentiality | |Are medical records maintained | | | | |
| | |securely and in a manner that | | | | |
| | |reduces the likelihood of | | | | |
| | |confidentiality breaches? | | | | |
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|Confidentiality | | | | | | |
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|Confidentiality | | | | | | |
| | |Does all office staff who has | | | | |
| | |access to patient information | | | | |
| | |receive training on maintaining | | | | |
| | |patient confidentiality? | | | | |
| | |Does confidentiality training | | | | |
| | |address: | | | | |
| | |Patient sign-in procedures | | | | |
| | |Procedures for relaying test | | | | |
| | |results to patients. | | | | |
| | | | | | | |
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| | |Procedures for facsimile (fax) | | | | |
| | |transmission of patient | | | | |
| | |information | | | | |
| | |Procedures for sending patient | | | | |
| | |information via electronic mail | | | | |
| | |(email)? | | | | |
| | |Has the office implemented | | | | |
| | |environment controls (e.g., | | | | |
| | |privacy windows, curtains) and | | | | |
| | |allocated private space for | | | | |
| | |patient registration, | | | | |
| | |examination, treatment and | | | | |
| | |discharge? | | | | |
| | |Is written patient consent | | | | |
| | |obtained for the release of | | | | |
| | |information from the medical | | | | |
| | |record in accordance with | | | | |
| | |applicable laws? | | | | |
| | |Has the physician practice | | | | |
| | |implemented procedures to comply | | | | |
| | |with the health information | | | | |
| | |privacy rule under HIPAA? | | | | |
| | |Do these procedures include the | | | | |
| | |following: | | | | |
| | |A notice of privacy practices and| | | | |
| | |authorization form describing | | | | |
| | |uses and disclosures of protected| | | | |
| | |health information (PHI) that the| | | | |
| | |physician practice may make, as | | | | |
| | |well as the patient’s rights | | | | |
| | |and providers’ responsibilities | | | | |
| | |with respect to PHI, which should| | | | |
| | |be provided to patients with a | | | | |
| | |good-faith effort to obtain | | | | |
| | |patient’s signatures | | | | |
| | |acknowledging receipt of the | | | | |
| | |notice before providing care. | | | | |
| | |A process for keeping records of | | | | |
| | |documented disclosures of PHI and| | | | |
| | |for accounting of and responding | | | | |
| | |to requests for disclosure made. | | | | |
| | |Has the physician practice | | | | |
| | |addressed the security of | | | | |
| | |individually | | | | |
| | |Identified protected health | | | | |
| | |information that is stored or | | | | |
| | |transmitted | | | | |
| | |Electronically, as required under| | | | |
| | |the HIPAA security rule? | | | | |
| | |Does the security plan include | | | | |
| | |remote access to office | | | | |
| | |information systems and the use | | | | |
| | |of portable computers such as | | | | |
| | |personal digital assistants? | | | | |
| | | | | | | |
| | |Does each provider and staff | | | | |
| | |member who is authorized to | | | | |
| | |access office information systems| | | | |
| | |have a unique password? | | | | |
| | |Are the electronic data systems | | | | |
| | |backed up periodically (e.g., | | | | |
| | |nightly) to avoid loss of | | | | |
| | |information? | | | | |
|Communication and Teamwork | |Is there a policy that requires | | | | |
| | |patient notification of lab | | | | |
| | |results and other tests, even if | | | | |
| | |results are within normal limits?| | | | |
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|Communication and Teamwork | | | | | | |
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| | |Is there a process for tracking | | | | |
| | |pending lab and other test | | | | |
| | |results, consultation reports, | | | | |
| | |and other pertinent documents to | | | | |
| | |ensure their receipt by the | | | | |
| | |practice? | | | | |
| | |Is there a mechanism to ensure | | | | |
| | |that lab and other test results, | | | | |
| | |consultation reports, and other | | | | |
| | |pertinent documents are | | | | |
| | |acknowledged and documented by | | | | |
| | |the physician before filing? | | | | |
| | |Is there a mechanism for | | | | |
| | |reporting urgent information to | | | | |
| | |the physician immediately? | | | | |
| | |Is patient notification of test | | | | |
| | |results documented? | | | | |
| | |Are patients told when test | | | | |
| | |results are expected and to call | | | | |
| | |in by a certain date if they do | | | | |
| | |not hear from the office? | | | | |
| | |Is there a mechanism to ensure | | | | |
| | |that arrangements are made for | | | | |
| | |recommended consultations, | | | | |
| | |referrals, or tests in a timely | | | | |
| | |fashion? | | | | |
| | |Are there protocols in place for | | | | |
| | |the use and documentation of | | | | |
| | |electronic communication (e.g., | | | | |
| | |email) with patients and or | | | | |
| | |between providers? | | | | |
| | |Are policies in place to govern | | | | |
| | |practice coverage arrangements | | | | |
| | |when physicians are unavailable? | | | | |
| | |Is the answering service notified| | | | |
| | |of these coverage arrangements? | | | | |
| | |Are covering providers in the | | | | |
| | |same specialty with a comparable | | | | |
| | |scope of practice available? | | | | |
| | |Do covering providers have | | | | |
| | |privileges at the same hospital? | | | | |
| | |Do covering physicians have | | | | |
| | |access to patient | | | | |
| | |records/information? | | | | |
| | |Do physicians provide covering | | | | |
| | |providers with a structured hand | | | | |
| | |off in communication regarding | | | | |
| | |any anticipated patient care | | | | |
| | |problems and a report on | | | | |
| | |hospitalized/acutely ill patients| | | | |
| | |before taking leave or becoming | | | | |
| | |unavailable? | | | | |
| | |Do covering physicians have | | | | |
| | |access to patient | | | | |
| | |records/information? | | | | |
|Americans with Disabilities Act (ADA) | |Does this review ensure that, for| | | | |
| | |example: | | | | |
| | |Parking spaces for disabled | | | | |
| | |persons are provided near the | | | | |
| | |entrance to the facility and are | | | | |
| | |clearly marked? | | | | |
| | |Signage is used to clearly mark | | | | |
| | |handicapped-accessible | | | | |
| | |entrances? | | | | |
| | |A drop-off area is provided near | | | | |
| | |the facility’s entrance? | | | | |
| | |Building and office entrance | | | | |
| | |doors are easy for disabled | | | | |
| | |individuals to open? | | | | |
| | |The office is wheelchair | | | | |
| | |assessable? | | | | |
| | |A pathway is provided from the | | | | |
| | |parking area to the entrance? | | | | |
| | | | | | | |
| | |Doors are wide enough to | | | | |
| | |accommodate people on crutches, | | | | |
| | |with walkers, or in wheelchairs? | | | | |
| | |The waiting area is large enough | | | | |
| | |to accommodate and | | | | |
| | |maneuver wheelchairs? | | | | |
| | |The rest rooms are handicapped | | | | |
| | |accessible and maneuverable and | | | | |
|American with Disabilities Act (ADA) | |the signage exists to indicate | | | | |
| | |this? | | | | |
| | |Examination rooms are handicapped| | | | |
| | |accessible and | | | | |
| | |maneuverable? | | | | |
| | |Hallways are free of obstructions| | | | |
| | |that may be obstacles to visually| | | | |
| | |impaired patients (e.g. | | | | |
| | |protruding water fountains, | | | | |
| | |telephones)? | | | | |
| | |Assistance can be provided to | | | | |
| | |disabled individuals who present | | | | |
| | |themselves for services (e.g. | | | | |
| | |sign-language interpreter for | | | | |
| | |hearing-impaired patients)? | | | | |
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| | |Has the practice arranged for | | | | |
| | |translators and interpreters for | | | | |
| | |patients of limited | | | | |
| | |English-speaking proficiency? | | | | |
| | |Americans with Disabilities Act. | | | | |
| | |42 U.S.C. 12101 et seq. | | | | |
| | |Is advice of legal counsel sought| | | | |
| | |when a complication results from | | | | |
| | |a physician’s actions and a fee | | | | |
| | |waiver or reduction is being | | | | |
| | |considered? | | | | |
| | |If a patient has an outstanding | | | | |
| | |bill, who makes the decision to | | | | |
| | |see or not see the patient? | | | | |
| | |Is there an area where | | | | |
| | |confidential discussions can be | | | | |
| | |held regarding | | | | |
| | |Billing and payment? | | | | |
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|CLIA (Clinical laboratory Improvement | |Do you have CLIA Certification? | | | | |
| | |Are the results of the assessment| | | | |
| | |used to improve office services? | | | | |
| | |Are records made available to the| | | | |
| | |new physician upon receipt of the| | | | |
| | |patient’s authorization? | | | | |
| | |Are reports and investigations | | | | |
| | |analyzed to identify areas for | | | | |
| | |quality and safety improvement? | | | | |
| | |Is there a committee or other | | | | |
| | |forum regularly held to | | | | |
| | |communicate quality and safety | | | | |
| | |issues and to discuss improvement| | | | |
| | |action plans and results of | | | | |
| | |actions taken? | | | | |
| | |Is feedback provided to the | | | | |
| | |practice managers, providers, and| | | | |
| | |staff? | | | | |
| | |Does the committee review reports| | | | |
| | |of patient-volume-adjusted events| | | | |
| | |(e., events per 1000 office | | | | |
| | |visits) compared to previous | | | | |
| | |reporting periods? | | | | |
| | |Does the practice endorse open | | | | |
| | |communication with patients, and | | | | |
| | |has it adopted a practice of | | | | |
| | |disclosing to patients when an | | | | |
| | |unanticipated adverse event or | | | | |
| | |error has occurred? | | | | |
|References: |
|AAACN competency standards |
|AAAHC facilities and environment core accreditation standard |
|AAAHC rights of patients, governance, and administration core accreditation standards |
|AAAHC diagnostic imaging services and pathology and medical laboratory services adjunct accreditation standards |
|AAAHC governance, administration, and professional improvement core accreditation standards |
|AAAHC clinical records and health information core accreditation standard |
|AACN Telehealth nursing practice and administration and practice standards |
|AAMI/ANSI standards for steam sterilization and sterility assurance using table-top sterilizers |
|AAON infection control standards |
|AAON continuous quality improvement/improving organizational performance, effective complaint management, and office safety standards |
|AAAHC rights of patients core standard |
|AAAHC quality of care provided core standard |
|AAAHC governance core accreditation standard |
|AAAHC rights of patients, administration and quality management and improvement core accreditation standards |
|AAON Confidentiality standards |
|AAON orientation and education of office staff standard |
|AAON Scheduling patients appointments standards |
|AAON Medical records standards |
|AAON continuous quality improvement/improving organizational performance, effective complaint management, and office safety standards. |
|AAP Infection control in physician’s offices |
|ACOG Sexual misconduct in the practice of obstetrics and gynecology: ethical considerations, 2002. |
|AGA standards for office-based gastrointestinal endoscopy services |
|AHIMA practice briefs, standards for the electronic health record |
|AHRQ Making Healthcare Safer. Chapter 42 Information transfer |
|Anti-kickback statutes. 42 U.S.C. 1320a – 7 b(b) |
| |
|CDC Guideline for hand hygiene in health care settings |
|CDC Final guidelines for preventing the transmission of tuberculosis in health-care settings. |
|CDC Updated interim domestic infection control guidance in the healthcare and community setting for patients with suspected SARS |
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|ECRI Physician office safety guide |
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|False Claims Act . 31. U.S.C. 3729-3733 |
|References Continued: |
| |
|FDA recall policies |
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|HRC Risk Analysis |
|HIPAA Privacy and security standards |
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|Imitation on certain physician referrals. 42. U.S.C. 1395 |
| |
|JCAHO National Patient Safety Goals |
|JCAHO surveillance, prevention and control of infection accreditation standard |
|JCAHO Management of the environment of care accreditation standard |
|JCAHO ethics, rights and responsibilities; provision of care; and leadership accreditation standards |
|JCAHO leadership and management of human resources accreditation standards |
|JCAHO Management of information standards TJC ethics, rights and responsibilities; provision of care; improving organizational performance, leadership and |
|management of human Resources accreditation standards addressing patient safety |
|TJC sentinel event policies and procedures |
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|Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human; building a safer health system. |
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|Medem eRisk Working Group for Healthcare Guidelines for online communication |
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|NCQA credentialing standards and guidelines for certification of physician organizations |
|NCQA quality management and improvement certification standards and guidelines for physician organizations |
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|OSHA regulations for occupational exposure to ionizing and nonionizing radiation |
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Corrective Action Form
Physician Practice Risk Management
Assessment Completed By: ___________________________ Date: _____________________________
|Question # |Action Required |Responsibility |Target Date |Action Completed |
| | | | |Date |Initials |
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-Assessment Questionnaires
Physician Practice Risk Managemetn
Assessment Completed by: ____________________________ Date: _____________________________
|Question No. |Action Required |Responsibility |Target Date |Action Completed |
| | | | |Date |Initials |
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