Patient Records Should Include Several Types of Information
Q. I am insured through The Psychiatrists' Program, the APA-endorsed Psychiatrists' Professional Liability Insurance Program. If I am involved in a lawsuit, how is defense counsel assigned?
A. In the event of an incident, you would immediately contact the Claims Department of PRMS, The Program's manager, at (800) 245-3333. The qualified claims staff member will discuss the situation with you and determine whether it is necessary to obtain counsel at that time. If counsel is needed, PRMS will contact the defense attorney, who in turn will contact you within a 24-hour period. Claims staff provides support and monitors the entire litigation process.
When it comes time to try a case in front of a jury or resolve a case after a favorable defense posture has been developed, you will find comfort in knowing you have coverage with a carrier that knows the importance of obtaining superior defense attorneys and experts for each participant. The Program has established a national network of experienced medical malpractice defense attorneys. The Program's defense attorneys have a particular expertise in psychiatric medical malpractice issues. Additionally, as many cases are won or lost at trial based on expert testimony, The Program's legal team also includes world-renowned experts as well as a local expert to provide support to the testimony as needed. More than 95 percent of lawsuits decided at trial or by a judge resulted in a verdict for our insured.
Q. I realize that it is important to keep patient records, but I am not sure what information I should include. Do you have any suggestions?
A. The primary purpose of documentation is to support patient care. Therefore, one of the goals is to create a document that accurately reflects what treatment was provided and why. A secondary benefit of good documentation is that it provides your best defense against allegations of malpractice. Courts view a carefully documented treatment record as a psychiatrist's testimony on his or her own behalf that he or she practiced responsible medicine during the course of a patient's treatment.
Some general guidelines regarding psychiatric recordkeeping are listed below. More information can be found at The Program's Web site at<www.psychprogram.com/Risk_Management/news_records.htm>.
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Document fully the type of treatment and rationale, as well as treatment alternatives and why they may have been rejected.
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Document dates (and length) of services, pertinent history, prescription of medication, and consultations with other professionals. Document legibly.
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When dealing with a potentially suicidal or violent patient, document all actions taken and why, and all actions considered but rejected and why.
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Include written informed consents, lab reports, and correspondence in the record.
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Record retention is often governed by state law. Keep in mind that there is no “statute of limitations” for licensing board or ethics complaints.
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Instruct staff regarding handling of records, stressing confidentiality concerns.
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Do not alter records after an adverse event.
Q. I recently joined The Psychiatrists' Program and noticed in the welcome packet that The Program offers a 5 percent risk management discount. How do I earn this discount?
A. There are currently three ways in which to qualify for the premium reduction, but please note that the specific education requirements and premium reductions permitted are governed by state statutes and regulations and, thus, vary from state to state. You can qualify by
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completion of at least a four-hour Program-sponsored or jointly sponsored risk management seminar;
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Successful completion of at least a four-hour non-Program sponsored risk management seminar pending approval by Program underwriter;
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Successful completion of the Program's Self-Evaluation Tool (SET), a self-administered, open-book risk management educational and evaluation tool.
This column is provided by PRMS, manager of The Psychiatrists' Program, for the benefit of members. More information about The Program is available by visiting its Web site at<www.psychprogram.com> or calling (800) 245 3333, ext 389, or sending an e-mail to The [email protected].▪
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Published online: 16 December 2005
Published in print: December 16, 2005
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