Risk Management

Risk Management Is Not Just for Physicians; All Personnel Should Know Their Limits and Duties

By Pamela Schremp, RN, MSN, CRNO

Argus, March, 1994

When registered nurses and ophthalmic medical personnel are added to an ophthalmologist’s staff, their scope of work must be incorporated into the practice’s risk management plan. Proper delegation of duties is important. Each staff member should know the limit and extent of his or her duties. The ophthalmologist is responsible for final informed consent and must be involved when critical medical decisions are made.

A physician’s responsibility for a patient begins with the first phone call. A clear, well communicated telephone triage system instructs front office staff on which questions to ask, what information or advice may be given over the phone, which patient problems require immediate notification of the nurse or physician and which require same day scheduling and, finally, how to document this process. Many offices provide staff with special message cards or pads for recording patient telephone conversations, which may be placed directly in the patient’s chart to create a permanent record of the call and the information provided. Patient care phone call record pads can be purchased from OMIC.

All staff should appreciate the importance of patient confidentiality and avoid discussing confidential patient information in the presence of other patients who are in waiting areas or exam rooms. If a staff member must take an urgent patient call in front of another patient, he or she should not reveal the caller’s name or telephone number.

Confidentiality of patient information extends to the medical records. Store patient records in a secure location. If records are placed outside exam rooms, patient names should not be visible. Avoid noting information about the person’s medical condition on the outside of the record. The outside jacket of one record included the following alert; “Becomes S.O.B. easily.” This comment could be easily misinterpreted by another patient as something other than shortness of breath. All staff should be familiar with the legal requirements on releasing medical records. Before releasing a medical record, obtain the patient’s consent. When possible, determine the reason for the requested release. When an attorney requests a patient record, it should be reviewed by the ophthalmologist prior to release. Assuring confidentiality of medical record information, including the results of diagnostic tests, is vital.

Although the patient must give consent when information is being disclosed to anyone outside the ophthalmologist’s practice, consent is not required when information is being shared or faxed to a satellite office of the same practice. However, any fax containing patient information should include a statement indicating its confidential nature and prohibiting its re-disclosure.

Front office and billing staff should be well versed in state laws governing disclosure of HIV-related information. In many states, patient consent is required to release this information to insurance companies and third-party payers. Staff members must know which accounts to bring to the attention of the ophthalmologist or the practice administrator before releasing them for collection.

Develop tracking systems and establish clear policies for processing diagnostic tests and results. Staff need to understand that no test result should be filed in the medical record until reviewed by the ophthalmologist, who should initial the lab result before it is filed.

Similar systems should be developed for tracking patient appointments and consultations. When a patient fails to show for an appointment, staff should try to determine the reason and document all communication with the patient, including making a note of the missed appointment in the patient’s record. The ophthalmologist should review all no-shows and the purpose of the missed appointment. When patients are referred to another physician, the referral letter should include a request to notify the referring ophthalmologist if the patient fails to keep the appointment.

In addition to handling ophthalmic emergencies, all staff, including the ophthalmologist, should be well versed in handling common medical emergencies such as hypoglycemia or vaso-vagal responses. Staff should also receive training in nonmedical emergencies, and a fire and evacuation plan should be developed for the office. Review office emergency plans annually and test emergency medical equipment regularly.

Clear communication and collaboration are the keys to successful risk reduction. By collaborating with professional, support and office staff, the ophthalmologist can better identify areas of potential risk and create strategies for promoting quality patient outcomes.