Risk Management Publications

CAP member physicians frequently call our hotline with questions about completing a patient’s death certificate.  Sometimes, they are reluctant to sign the legal document since they were not in attendance at the time of death. Other times, they inquire if their nurse practitioner or physician assistant can sign the death certificate for them.

Most physicians would likely not be surprised that many American homes have an accumulation of unused, unwanted, or expired medications. But did you ever consider the potential safety hazards these surplus medications present?

As new information emerges daily around the Coronavirus and as the search for answers continue, the risk management and patient safety experts with the Cooperative of American Physicians, Inc. (CAP) would like to ensure that physicians and medical communities across California have access to the most reliable resources to remain aware of the latest strategies in treatment, protection, and prevention. 

Electronic Nicotine Delivery systems (ENDS) are the newest emerging technology in the epidemic of novel tobacco products that has been spilling out of start-up companies for the last 13 years. So physicians wonder, “How should I respond when my patients seek advice about using these electronic devices?”

Medical practices frequently receive medical record release requests from multiple sources, including subpoenas, attorney letters, and patients themselves. Learn the answers to several frequently asked questions by patients.

Here is the question asked most often on our risk management hotline: How long should our office retain patient medical records and billing information?

A frequently asked question to the CAP Hotline is: Our practice wants to offer "Microdermabrasion". Can the procedure be done by a trained medical assistant, under the supervision of a physician? The answer is no.

California law provides that any adult patient and any minor patient authorized by law to consent to medical treatment, is entitled to inspect and request a copy of their medical record upon written request to the healthcare provider and payment of reasonable costs to make the record available.  (California Health and Safety Code Section 123110)

CAP's Risk Management and Patient Safety Department offers the following guidelines to help physicians who are retiring or otherwise closing or selling their practice, or for those handling the estate of a deceased physician.

Many physicians have migrated to the electronic record in the in-patient and out-patient setting. Physicians routinely use electronic and digital signatures in lieu of a hand written signature. Electronic submission necessitates security measures to verify and authenticate the physician’s identity.

So far this year, business associate breaches account for roughly 12 percent of the total breaches reported to the Office of Civil Rights (OCR), or 27 of the 233 reported breaches as of September 19. What does this mean to a covered entity? It means that it’s not enough to require a signed Business Associate Agreement (BAA). Vendors should be diligently vetted.

The Department of Justice (DOJ) has certified California’s Controlled Substance Utilization Review and Evaluation System (CURES). Effective October 2, 2018, it will become mandatory for all health care practitioners to consult and review the CURES 2.0 system prior to prescribing, ordering, administering, or furnishing a Schedule II-IV controlled substance.

In part 1 of our article for Healthcare Risk Management (HRM), we outlined the issues of informed consent and informed refusals and what steps to take to protect your practice. In part 2 of our article, CAP’s Risk Management and Patient Safety Department will list the strategies and safeguards to have in place when working with advanced healthcare professionals.

CAP is pleased to offer members compliance training through Evolve e-Learning Solutions. This platform offer members an easy to use, interactive online training system. This allows physician practices and their staff to receive quality training at the fraction of the cost of classroom training.

Envision a scenario in which an adult brings a minor into your office. During check-in, it is revealed that the minor does not live with their parents but “lives with” the adult accompanying them. The adult in question could be an aunt, a grandparent or a cousin. Having a minor “live” with them does not mean for an afternoon, weekend or while the parents are on vacation. It means the parent is actually “absent” perhaps living in another state, country or maybe in jail; therefore, the minor lives with this person.

We all know patients in California have a right to review their medical record and/or obtain a copy. It is also no surprise that healthcare providers are typically allowed to charge a fee for this service. However, with all the different rules and exceptions, copying fees can be confusing.

Security is a top concern with patient portals. Providers grant patients access with a secure username and password. It is important to choose a patient portal vendor that provides a system which allows the practice to be HIPAA compliant. The provider should establish procedures which are structured for optimal security.

The front office staff discussing weekend plans, old magazines askew and the smell of a tuna sandwich permeating the waiting room can make a big difference in the patient experience. A negative impression can leave a patient less likely to follow patient treatment plans and recommend your practice to others.

The office receptionist is the first, and sometimes only, person patients and their family members may meet prior to any medical services.