In January 2008 both MGO and PLPP’s Boards of Directors approved the formation of a Risk Management Committee. The primary role of this committee is to:
“Assist MGO physicians and their practices in having actionable risk management strategies which will serve as tools to enhance patient safety and quality of care while decreasing the potential risk of financial loss from both an operational and legal perspective”
As we begin to explore opportunities to meet this objective, the committee determined it was important to start with some basic documentation rules used in patient charting with the focus on patient problem lists, medication lists, and allergy lists.
Placing the problem list, medication and allergy lists in the front of the chart allows for quick review, updating and accessibility for physician including cross coverage. 2008 JCAHO recommendations include to accurately and completely reconcile medications at visits, hospitalizations and surgery; to improve safety of using medications (look alike medicine names) and improving standardization during “hand off” communications are all made more effective if the lists are readily available at the front of each chart.
In a recent survey conducted with random MGO practices, it was noted that while 94% of the practices surveyed had completed medication lists within their patient charts only 73% placed those lists at the front of the charts for easy identification. The survey also highlighted that in those same practices, 91% maintained an allergy list while only 67% had a standardized problem list at the front of patient charts. Additionally, greater than 80% of the time both the allergy and medication lists were updated at each visit with only 66% of the problem lists being updated.
Physician-patient communication is the most important line of defense in the prevention of a lawsuit. Patients who have a positive relationship with their physician are less likely to file grievances and/or lawsuits against them. This relationship begins at the initial visit, where the patient’s problem list, medication documentation and known allergy lists are formulated. At each subsequent appointment, updating of these lists demonstrates the physicians concern for the problems the patient is experiencing, reduces risk and improves the quality of care being delivered.
Approximately one-quarter of the adult population in the United States is functionally illiterate. While formulating the lists, try to simplify the language and material given to the patient. Speak using common words, not jargon. Ask the patient to “teach back” or repeat the instructions to assure their understanding. Write legibly and identify each list with patent’s full name and medical record number. Correct any errors or changes on chart by drawing a single line through entry, signing and dating with reasons for change. NEVER OBLITERATE ENTRY!
The Problem List
The “problem list” may be simple or complex as standardized by the practice. It should include a current list of major acute and chronic problems. The problems should be dated at the time of recognition and resolution. ICD-9 numbers may be assigned as well as a brief description if desired. Past surgeries and hospitalizations will herald the need for medication and allergy reconciliation. Family history, social history, and education level should also be considered as complexity increases. A place for signatures and/or initials is important if multiple caregivers make entries and updates. This problem list is ideally updated at each visit to ensure accuracy and enhance physician/patient communication.
The Medication List
Medicine errors are thought to be the most common type of medical error, especially in pediatrics (JCAHO). Medication errors are common and most frequently occur during the prescribing and administering of the medicine. It has been estimated that 1.5 million patients are harmed or killed by medication errors each year (Institute of Medicine 2006). Almost half of those errors occur during the admission or discharge of the patient. Medication reconciliation is important to prevent these errors during transition (to hospital, consultants, out- patient surgery) and/or at subsequent visits to a physician. It is extremely important to update the medication list to reduce these errors and risks. A key strategy to prevent medication errors is to engage the patient and family in the process. A “home medication list” which isupdated and provided to the patient after each update, will reflect current medications to other providers.
During the initial visit, it is recommended that the physician obtain a complete list of medication. This list should include:
- prescribed medications
- alternative and holistic medicine
- over the counter medications
- herbs, supplements, vitamins
- recreational drugs
- sample medications
A standardized list of abbreviations (doses and symbols), as well as the frequency and dosage of each medication should also be included. The route of administration and the date to help determine length of time patients have taken the medication is important, especially with narcotic medicine. Medical record documentation in notes is also recommended as well as updating the medication list, which is in the front of the chart.
To assure compliance and completeness of the list, formulate a medication list that can be mailed to the patients prior to the initial visit and then review this list when the visit occurs. Another option is to request patient brings all medicines to the initial visit. It is recommended that this list is updated at all subsequent appointments. A copy of the updated list can be provided to the patient. This will improve communication and medicine safety, while improving overall patient care and reducing risk.
When telephoning prescriptions to pharmacy or verbal orders to hospital, extended care facility, or patient (or family), keep a log detailing:
- patients name (or family member)
- special instructions
- discussions of side effects
Place copy or original in the chart and update the medication list. Document adverse reactions and/or side effects in medical record. Any “off label” use of medicine should be documented with reason for use. Any reference to accepted standards or journals help document intent.
The Allergy List
The rationale for updating the allergy list has been elaborated upon in the preceding. A list, “at the front of the chart”, clearly labeled (in red!!) detailing allergies to both medicines and foods allows for early review and updating as necessary. Adverse reactions can also be described. It is suggested that allergies be listed in the medical record as well as the list in the front of the chart. It is again recommended that this be updated at each and every visit.
While the above information may be simplistic in its nature, adherence to guidelines such as these, offer physician practices opportunities for improvement. It is the intention of the Risk Management Committee to assist practices in standardizing policies and procedures that will not only improve patients care but proactively reduce risk and errors.