Be ready and alert for malpractice issues by implementing risk management procedures

Proactively reviewing practice procedures will lessen your exposure to malpractice. The risk of losing patient confidence, staff respect, and worse, your practice, is real. The best solution is to be proactive and rely on common sense and practice management. Review your office procedures and specific adjustment and therapy techniques, as well as staff scripts and patient interaction.

Occupational Hazard
When I taught graduating students at Life University, I advised that being protected with malpractice insurance was not an elective but a necessity. Malpractice insurance may be on the new graduates’ long list of expenditures, but it should be the first check written. The umbrella of asset and practice protection far outweighs the expense. If you are without malpractice insurance, speak with a few insurance companies representing our profession, and decide the best policy limits and type for your practice. Choices may vary slightly and be dependent on how and where you practice.

If someone falls in your parking lot, on the steps to your office, or trips on the carpet, this is not considered malpractice, but still leaves you vulnerable to lawsuits and expenses. In this instance, office liability insurance is needed. Insurance premiums are low when compared to the protection, which can include office content, fire, and theft protection. For added asset protection, purchase an umbrella policy on your homeowner’s policy. Financial risk can be covered by obtaining disability and overhead insurance. Protection is the first line of self-defense and asset management.

Ringing in New Patients
As health care providers, we are professionally responsible for every person who completes a case history form. After reviewing a completed case history form and deciding not to accept them as patients, we are also responsible for what we did or did not advise. Any advice or lack thereof may be considered a potential risk. Advise potential patients conservatively, and if rejected as a patient, offer a referral or another avenue for further advice, which should be noted on case history forms. If you are called to testify or questioned, the information is in your files.

Case history forms come in various shapes and sizes. Preexisting conditions, previous surgery, prior health care treatment, and other risk concerns—such as bone, disc, neurological, vascular disease, or radicular type symptoms—are red flags that must be noted. To go one step further, you may request medical records, previous radiographs, and/or reports and explore further with diagnostic testing. Risk management always begins with proper communication.

Don't Cram the Exam
We are by nature conservative health care providers, since our methods and diagnostic procedures are generally noninvasive. The purpose of evaluations is to render judgments toward patient care and/or proper referrals. It may be rare to send a patient to another chiropractor or medical specialist. Not doing so when necessary borders on malfeasance.

Questionable X-rays should be retaken and referred to a chiropractic radiologist or a local hospital radiology laboratory. Proper diagnostic X-rays of the spine include an AP and lateral view. Keep current with X-ray procedures and diagnostics by attending postgraduate classes.

Specific testing to rule out strokes, such as George’s test, proves that you attempted to provide an objective test. Each established and proactive procedure adds to a solid defense. Know the rules and regulations of your respective state.

Never leave patients in the dark—always share treatment goals and results. Patients who see the vision are compliant and will refer others. Also, if a problem does occur, they are more apt to forgive and forget.

When patients are gowned, they are in a vulnerable position, especially women. An innocent remark or gesture could be perceived as an offensive act, which results in the loss of patient confidence, the loss of a patient, or worse, a lawsuit. Discuss what you are attempting to do and always be aware of the patient’s dignity.

Always listen to the patient. A fearful patient forced to withstand your method of care creates a breach of confidence. Report your findings by reviewing X-rays, examination findings, and subjective complaints with them. When outlining treatment goals, keep it well within the realm of possibility. Outrageous claims and false hope pose potential problems. Never guarantee results.

Risky Business
Keeping proper records: Chiropractors are notorious for not keeping legible, coherent records and notes. It is prudent to keep a clear rationale for the care plan, including X-ray findings and correlation of the evaluations. Proper practice management begins with the first visit and continues while patient records are in your possession. Each state varies in the required time to hold records. Keep your records in a safe place, preferably fireproof. All correspondence concerning patients should be copied.

Fees and billing are usually subjects that can upset patient/doctor relations. As much as we deserve full payment for services rendered, this often leads to miscommunication and potential patient upset. Persistent billing and threats may lead to nuisance lawsuits based on frivolous accusations. Clean up billing and collection concerns and discuss patient financial obligations early in the treatment.

A SOAP format is recommended for daily notes. Be sure a legend accompanies every page. Consent forms for minors and pregnancy are also useful forms. There should be a notation of everything you provided for patients in their file.

If you plan to offer a cash plan with prepaid services, I recommend a service contract outlining paid services, and how payment will or will not be returned if patients do not use the services. There are many of cash-oriented seminars and consultants to guide you.

Equipment and supplies maintenance: During therapy, be cautious of all necessary equipment and materials. Creams and gels should be nonallergenic; electrical devices should be grounded to reduce spikes and surges; and pads should be clean and for individual use. Check all therapy equipment and motorized mechanical traction tables on yourself. Service all equipment as recommended to avoid expensive surprises later.

Abandonment issues: Patients who leave prior to a final evaluation or discussion have received incomplete care. If their condition deteriorates, and they seek a medical opinion with a doctor who is not appreciative of chiropractic, they may file a liability claim. When patients do not complete their treatment plan without an official release, they require a completion letter. Send a letter requesting they contact your office concerning the recommended care schedule. Offer a referral to another chiropractor or medical specialist closer to their work or home. Also, record the number of attempts to contact them.

Sexual advances or perception: Many state boards of examiners are hearing more and more sexual complaints. Watch what you say and do. Although meant as an innocent remark or hug, patients may not perceive it as such.

Since chiropractic is a "touchy, feely" profession, we need to be careful when examining and adjusting our patients. Many procedures require our hands to be placed on delicate and personal areas. Biomechanically, this makes sense, but in the rush to see the next patient, we may forget to explain the procedure, which leaves the patient with questions and doubts. Be aware of this, and keep each patient informed.

Reality Check
A few months ago, one doctor received a letter from the state board of examiners requesting an appearance before the hearing board because of a patient complaint. When the chiropractor appeared before the state board, he clarified the issue, which was a matter of perception. Even the best of us have some ghosts in our professional closets—words that should have been left unsaid, procedures that were questionable at the time, and staff that were let go with bad feelings on both sides.

Dealing with the public, especially as a "hands on" chiropractor, has built-in risk. Consider the number of patients seen and adjustments performed—it is just a matter of time before you may be called to the carpet.

Risk management is being cautious, not paranoiac. Causing you to look over your shoulder in fear is not my intent—my purpose is prevention. Your malpractice insurance company, state association, and state board ethics committee are the best sources for managing risk.

About the Author
Joel E. Margolies, DC, has an active practice in Tucker, Ga, and was an instructor at Life University in Marietta, Ga. Margolies is also the author of a series of chiropractic books, including Smart Start, Workshop Workbook, Chiropractic Marketing and Public Relations Workbook, and Personal Injury Workbook. He sends a free weekly email newsletter concerning practice management, public relations, and philosophy to more than 8,000 chiropractors in 31 countries. Margolies can be reached via email: joel3639@aol.com, or website: www.chirosmart.net.