practice of Medicine
Orthopedic Surgery Toolkit
Referrals and consultations
There will be times when some patient’s clinical problems may be beyond a physician’s expertise or specialty, and the use of a consultant is warranted. Below are listed some of the most common situations when a consultation is needed.
- It is advisable for a physician to obtain a consult when he/she is uncertain about the diagnosis or treatment, especially when the patient’s problem is outside of the physician’s specialty or when the patient’s particular condition is ordinarily treated by another specialty or subspecialty.
- If an adverse outcome is anticipated, seek the advice of a second physician.
- If the patient or family requests a second opinion, get a consultation.
- Use a consultant if an alternative or combined therapy involving another specialty can be considered.
- When the handling of a case is questioned, obtain a consultation.
- Obtain a consultation when the patient does not respond to treatment as expected.
After a physician decides a consultation is needed, it is suggested that the physician take certain measures to ensure communication between the providers. The following guidelines are recommended:
- Document the reason for the consultation in the patient’s chart.
- Explain to the patient the need for and purpose of the consultation.
- Communicate orally with the consultant, especially in serious and urgent cases.
- Provide the consultant with a complete history and records of the case along with an opinion.
- Document the rationale for the treatment if it is different from the consultant’s recommendations.
- Ensure there is a clear understanding among the patient, primary physician and consulting physician, as to who is responsible for the patient’s continued care.
- Track to make sure the patient keeps the consultative visit.
The consultant also has communication responsibilities to the patient and physician. These responsibilities are listed below.
- Inform the responsible physician and the patient of complications that might arise from procedures the consultant carries out.
- Communicate the findings and recommendations to the referring physician and patient in a timely manner.
- Provide a complete copy of the consultant’s report to the referring physician.
- Notify the referring physician if a patient does not keep an appointment with you, the consultant. If a referring physician doesn’t receive correspondence from the consultant within a designated time frame, he/she should check with the patient first to determine patient compliance. Document the conversation with the patient, and proceed according to your office policy or system protocols. Usually, Risk Management recommends up to three separate reminders per patient in high risk situations and/or when providers are in diagnostic pursuit.
Reconciling test results
Communication among the healthcare team and coordination of care is critical to improving patient outcomes and reducing professional liability claims. Whether the practice utilizes an electronic medical record or a manual system, reliable follow-up systems are important for providing safe care. While providers should not be held responsible for the actions taken or not taken by patients, it is reasonable to expect the healthcare team to advise patients of necessary tests, educate them about the risks and benefits of recommended treatments, keep them informed of the results, and provide follow-up as indicated. Documentation of the process is necessary to demonstrate that the patient was informed.
This involves maintaining reliable processes to follow-up with patients who are undergoing screening or diagnostic testing, as well as those who are referred to other providers for further evaluation and treatment.
Providers are encouraged to design reliable processes that recognize and address opportunities for system failures. In doing so, the practice will be better equipped to improve patient safety and reduce the risk of a professional liability claim. A well-designed tracking system includes:
- a patient follow-up process
- a test tracking management system
- a referral management system
- a mechanism for documenting informed agreement and/or refusal
A test results management system identifies all essential screening and diagnostic tests ordered and performed (within or outside the office.) Tests performed outside the office tend to be the most problematic to track.
Essential tests include the following:
- all tests ordered during the work-up of a critical or acute problem.
- tests ordered where subsequent follow-up is essential, and the risk for not following-up is high.
- tests ordered to monitor medication levels with known adverse effects such as INR levels for patients on anticoagulation therapy. Other examples include diuretics, cholesterol-lowering drugs and certain antibiotics.
- tests ordered in which the specimen (blood, pathology, etc.) is obtained in the office but sent elsewhere for testing.
Components of a well-designed test management system include:
- a process where the patient is involved in the identification process prior to any specimen collection and using two forms of patient identification, excluding the room number.
- a process for tracking pending lab results that ensures their receipt by the practice as well as a method for identifying test results that are not received.
- a mechanism to ensure that test results are reviewed and acknowledged by the provider.
- a process for patient notification of test results and for such notification being documented in the medical record.
- a process that ensures follow-up of any additional testing/monitoring required/needed.
Maintaining a reliable and effective clinical tracking system requires teamwork and an ongoing willingness to monitor performance and process issues. Because of its significance in reducing the risk of adverse patient outcomes and professional liability risks, practices are advised to routinely evaluate the effectiveness of its systems, identify potential system failures, and address any opportunities for improvement. Maintaining an effective clinical tracking system is the most labor intensive processes within a medical office, yet one that can most effectively ensure quality patient care.
The importance of patient follow-up
Doctors are busy. They don’t have time to chase after patients and ensure they are taking their medications, getting the prescribed tests, and proceeding with the discussed treatment plan. With no show rates falling anywhere between 5 and 55 percent, doctors are struggling to get their patients in for appointments. When it comes to patient adherence and follow-up, who is responsible?
According to an article in the American Medical News, medical liability experts believe missed appointments and failures to follow up are a great legal risk for physicians. While experts work on systems to make follow-up more streamlined, we wanted to provide some actionable advice you could implement now.
- Make reminder calls – Patients are busy too, sometimes they need to be reminded about an appointment they made a few weeks back.
- Reduce wait times – This isn’t always an easy one. We understand that doctors need to spend as much time as necessary with a patient to get to a diagnosis and develop a treatment plan. But reduced wait times, often leave a better impression on the patients mind, making it more likely they will return for follow-up appointments
- Create a welcoming reception area – This may sound superficial, but if a patient has to spend more than 5 minutes waiting for their appointment to begin, it’s better they do so in an aesthetically pleasing environment. Again, this helps leave a better impression on the patient, making it more likely they will return.
Though the aforementioned tips may increase the likelihood that a patient will keep their appointment and come in for their follow-up, they won’t help in the event that patient doesn’t show. While there may not be an absolute solution for eliminating your liability risk in regards to patient follow-up there are a few things that are important to keep in mind.
- Documentation – Keeping thorough documentation of your emphasis on the importance of a follow-up test, or prescription and the patient’s understanding of that importance is something all experts agree can help protect physicians.
- Reasonable attempts to contact – If a patient misses an appointment or skips a recommended test, even if the doctor has documented the importance of said test or appointment, the doctor is not relieved of legal implications. You must make an effort to contact the patient and reschedule or reinforce the importance of the required test. Be sure to document each attempt to contact the patient and any explanation the patient may give.
With few hours in the day, many appointments scheduled, and numerous patients to see, the patient follow-ups may slip through the cracks. It’s important, however, to develop a system that works for you and your organization to ensure that they don’t. You can’t make a patient proceed with a treatment plan, follow up with tests, or take prescribed medication, but you should attempt to contact and thoroughly document those attempts in the interest of your patient and yourself.
Saboo, Alok. 2015, January 8. Best practices for improving care with patient follow-up. http://www.fiercehealthcare.com/node/124161/print
Lerner, M.D., Barron H. 2014, November 2. When Patients Don’t Follow Up. http://well.blogs.nytimes.com/2014/11/13/when-patients-dont-follow-up/?_r=0
Gallegos, Alicia. 2013, July 15. Medical Liability: Missed follow-ups a potent trigger of lawsuits. http://www.amednews.com/article/20130715/profession/130719980/2/
Handoffs may be described as the process of transferring primary authority and responsibility for clinical care from one departing caregiver to another incoming one.
Patient handoffs are a necessary component of current medical care, but come with risks. “Handoffs” or transitional errors are among the most common and consequential errors in healthcare. Most patients do not stay in the same place and are not cared for by a single set of doctors and nurses. Handoffs occur naturally as patients move throughout the healthcare system.1
There are various types of handoffs. A patient-related transition may occur because a patient is referred from a primary care provider to a subspecialty physician, or a patient is discharged home from the hospital. A provider-related transition may occur when a patient is stationary, but the providers change due to reasons such as call change.2 When a provider delegates the duty to another provider, the provider who is assuming responsibility for patient care must be aware of the responsibility and have access to all patient information. Covering providers should communicate directly with each other before coverage arrangements begin.
Consider the following recommendations to reduce the risks of handoff communication:
- Implement structured hand-off and sign-out protocols that include an opportunity to ask and respond to questions for the purpose of ensuring continuity of care and safety.
- Structure hand-off communication to include up-to-date information regarding the patient's treatment, condition, and highlighting any recent or anticipated changes.
- Communicate with covering physicians regarding any limitations for prescribing and refilling medications, and issues related to the coordination of care with other providers or specialists.
- Agree about documenting all patient encounters, including before, during and after the hand-off event.
- Schedule a date and time to communicate as soon as possible after coverage ends to discuss patients who experienced serious or unusual problems.
Major transition and handoff issues occur in community practice. The volume of patients seen in the outpatient setting magnifies the problem with handoff communication. We advise that careful consideration be given to the process of handoff communication in order to reduce risks and improve patient safety.
The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.