Lesson Learned from Sophia's Case

Notes of Best Practices

Episodes of risk often occur when best practices are overlooked. The following are common themes for risk and brief notes on their accompanying best practices that are relevant to this case. Learn more about any of these critical topics through your Risk Management Consultants at Physicians Insurance.

Encounter planning/patient flow

  • Schedule time according to the type of visit.
  • For new or complex patients, consider agreeing on a number of issues to be addressed at the current visit and schedule future visits for additional, identified issues. 

Follow-up scheduling and tracking 

  • If possible, schedule follow-up appointments before the patient leaves. 
  • Have a system in place to send out reminders to patients if a follow-up appointment is missed or cancelled without reschedule.

Coordination of care

Be sure to talk with the patient about other providers involved in the patient’s care.

  • Agree on which providers should be seen for what:
    • Routine specialty care, such as women’s health specialists 
    • Specialists for problemcentric or chronic care
  • Discuss importance of need to see other providers
  • Circle back with patient about whether care has been given by other providers.
  • Document review of outside/consultant reports.


Patient-provider communication:

  • Agree on issues, importance of complaints.
  • Agree on priorities for current and future appointments.
  • Agree on plan for immediate, higher-priority complaints.
  • Agree on plan for addressing additional, open complaints.

Provider-provider communication:

  • Be clear about relevant clinical information when referring a patient for a diagnostic or to a specialist.
  • Order accurately—screening and diagnostic are different.
  • Ordering provider and other treating providers should communicate and agree on a follow-up plan.


  • Key to managing care; it builds a foundation upon which to work.
  • Key to defending care; it is the only contemporaneously compiled history of care.
  • Providers need to clearly document plans for:
    • Treatment
      • For work-up of high-priority complaints and next steps for additional complaints
    • Follow-up
      • Tracking and communication with patient about expected follow-up
      • With specialists/other care providers