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Medical Record Documentation: Paint The Clinical Picture with Complete and Accurate Documentation

Medical record documentation errors continue to play a significant role in medical malpractice claims. Incomplete and inaccurate documentation can lead to a variety of unintended consequences including delayed diagnosis or misdiagnosis, patient harm, and death, any of which can lead to medical malpractice claims. Documentation errors encompass missing or incorrect information in charts, notes, transcriptions, and other electronic health record (EHR)-related areas. Copy/forward and drop-down menu functions, the ability to easily document on the wrong patient or in the wrong location of a chart, and late entries that may appear concurrent are all documentation issues that can cause patient injuries and/or impact the defense of a lawsuit. Certain aspects of the medical documentation process may invite behaviors that contribute to errors and inappropriate notations, increasing the likelihood of later liability.

Vicarious Liability for Medical Assistant Negligence

Medical assistants (MAs) can increase medical practice efficiency, patient satisfaction, and patient care quality. Increased satisfaction and quality can reduce malpractice liability risk. But MAs can also increase liability risk for their supervising/delegating clinicians and employers. Physician employers of MAs may be found vicariously liable for MAs’ negligent actions and may also be directly liable for negligent supervision, delegation, hiring, and/or training of MAs. Additionally, MAs who exceed their own scope of service to the degree that they are practicing medicine (or nursing), can expose the person delegating tasks to charges of aiding and abetting the unlicensed practice of medicine (nursing), which can result in board discipline and criminal prosecution. MAs who perform tasks outside of their scope can be charged with the unlicensed practice of medicine (nursing), which is a crime. This article focuses on what employers can do to reduce vicarious liability risk associated with MAs.

14th Annual "Caring for Our Future" Medical Scholarship Fundraiser

Each year, Riverside County Medical Association awards scholarships to deserving and committed medical students and early-career physicians who have committed to returning to practice in Riverside County following their training. We are able to offer these scholarships as a result of the funds raised at our annual “Caring for Our Future” Medical Scholarship Fundraiser. This year, we invite you to help us celebrate “The Magic of Giving: Supporting Tomorrow’s Heroes" on Wednesday, October 30, 2024, at the Riverside Convention Center.

Medical Practices are Subject to the New Corporate Transparency Act

Did you know that your California medical practice is a corporate entity? It is, and there is new federal legislation called the Corporate Transparency Act (CTA) that went into effect January 1, 2024, which will impact your practice. The CTA requires compliance by December 31, 2024, which is only four months away, and failure to do so will result in the imposition of unnecessary penalties. Don’t stress, however, as Thakur Law Firm, APC (TLF) will help your medical practice comply with the CTA.

Workplace Bullying and Its Effect on Patient Safety and Liability Risk Exposure

Bullying can decrease patient safety and increase liability risk. The stress, anger and frustration resulting from even mild incivility can interfere with working memory, which, in turn, adversely affects cognitive functions necessary for medical decision-making and procedural performance. Bullying undermines coordination, collaboration, teamwork, and communication, which are also essential to delivering safe patient care.

Treating Family: Liability, Ethics, and Professionalism

A physician-patient relationship exists solely for the patient’s benefit. The very first code of medical ethics drafted by the American Medical Association (AMA) in 1847 recommended against physicians treating family members, stating, “the natural anxiety and solicitude which he [the physician] experiences at the sickness of a wife, a child . . . tend to obscure his judgment, and produce timidity and irresolution in his practice.” In addition to the current AMA code of ethics, several major medical professional associations generally discourage the provision of medical care for family members.

RCMA 2023 Year in Review

Thank you for your membership and support which enables us to continue supporting the practices of Riverside County. Together we will continue representing the best interests of Riverside County physicians and the patients you serve.

A Message from RCMA's President

It is my honor to serve as RCMA’s 131st president, following in the footsteps of a long line of outstanding physician leaders. Throughout this year, I am excited to help lead RCMA’s pursuit of our strategic objectives of supporting physician wellness, increasing the physician workforce, helping practices optimize to the new models of care, and continuing to grow our membership.

Informed Refusal Documentation

Appropriate, consistent, and accurate medical record documentation is a key aspect of patient safety and liability risk management. What is, and more often what is not, documented in the record can be the pivotal factor in a malpractice lawsuit. In this article, ProAssurance shares the informed refusal process for documentation.

Is It Safe to Send That Text? The Patient Safety and Liability Risks Associated withText Messaging.

Texting in a healthcare environment has risks and benefits. In the following article, Mary-Lynn Ryan, Senior Risk Management Consultant with ProAssurance shares ways to avoid risk when using text technology in your practice.

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