Popular RM Topics - Patient SAFE

National studies have cited ten medical chart documentation standards that are associated with improved patient safety. Providers who have scored high on compliance of these standards have had fewer malpractice claims. The survey designed for this project uses the following ten standards to assess your practice:

1. Use of problem and medication lists
2. Prominent notation of allergies/adverse reactions
3. Use/documentation of telephone triage
4. Effective on-call after-hours coverage
5. Legible medical records with correct notation of errors and additions
6. Informed consent documentation
7. Use/documentation of patient follow-up tracking system
8. Use/documentation of test tracking system
9. Use/documentation of consultant tracking system
10. Signing of incoming reports

We know that failure to implement these valuable patient care standards has resulted in significant and expensive claims. Physicians Insurance is committed to helping you provide quality care and reduce the likelihood of claims and lawsuits. By implementing the above ten standards, you promote patient safety and reduce the risk of claims. While the best medical care cannot always prevent adverse outcomes, proper documentation can demonstrate that effective systems were employed to prevent them, that potentially serious conditions were carefully considered during the clinical evaluation, and that these considerations were communicated to the patient.

Following are some articles and tools designed to help members address these critical issues.

Articles

Electronic Records Can Help You Build a Patient SAFE Practice (PDF 35 KB)
Enhancing Health Care Quality Improvement Activities with Patient SAFE (PDF 35 KB)

Patient SAFE Medical Practice Toolkit (PDF 116 KB)

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