Many practices list all lab test orders in a spiral notebook and cross them out once the results come in. Others create a reminder system with calendars. After the doctor orders a test or referral, a staffer marks down when a test result or consult report is expected back—three weeks later, perhaps. When that date rolls around, someone checks to see if the information has made it into the office, and if it hasn't, he finds out why.

Systems should be redundant. Say you have a bin of charts with pending test results. But what if the results never come in, and meanwhile the chart is snatched by a billing clerk and then shelved in the file room by mistake? "I've seen that happen," says Willis. "You could prevent that mistake by using an out card in the file room stating that the record was pulled for a pending test." Some practices put a jumbo paperclip on their stacked-up pending charts to make sure nobody files them away accidentally, adds Lembitz.

2. Don't let reports slip through the cracks

Typically, lab results, X-ray summaries, and consultant reports are attached to the front of patient charts and placed on the proverbial pile in the doctor's office. Most doctors earn good marks when it comes to reading and initialing these papers. But the system breaks down when a staffer sticks the paper in the chart and then shelves it in the record room without the doctor seeing it, says San Francisco GP and law-school graduate Dan Tennenhouse, who lectures on legal issues at the University of California-San Francisco School of Medicine.

"It's poor training," says Tennenhouse. "You often see these kinds of mistakes with temporary employees, who don't always learn all the details of their job."

Again, EHRs come to the rescue. With a more comprehensive program, outside reports flow into the EHR—as an e-mail attachment, a scanned image, or a direct transmission, say, from a lab—and queue up in the doctor's to-do list on the screen.

Some physicians feel so overwhelmed by incoming reports that they delegate review to a medical assistant or RN. This method is okay, says Lembitz, provided it's governed by written protocols, such as requiring all positive or borderline results to be forwarded to the physician.

3. Have patients call for test results

Do you tell your patients, "If you don't hear from us, that means your test result was negative"? It may sound expeditious, but this way of handling test results can lead to a malpractice claim, says attorney Deborah Willis.

"What if the practice never receives the results from the lab, or what if they were filed without the doctor reviewing them?" says Willis. "That's why you should tell patients to call the office in two or three weeks if they haven't heard anything. It's another safety net."

4. Maintain an updated medication list

To avoid drug interactions and determine dosages and frequencies of prescribed drugs, you need a medication list in the front of every patient's chart. "If you try to collect all that data by flipping through the chart, you're setting yourself up for a big fall," says Willis.

Maintaining this list is a challenge for doctors, says COPIC's Alan Lembitz. "Only 60 percent of practices audited by COPIC met our medication-list standard in the first half of 2004," he admits. Of the remaining 40 percent, lists were either missing, out of date, or incomplete—lacking dosage and frequency information, refill instructions, or any mention of samples, over-the-counter medications, and herbal remedies. EHRs provide an obvious solution, since most programs automatically generate—and update—the list as you write prescriptions. Having your assistant review and update the list each time the patient comes in will work, too.

5. Document patient phone calls

COPIC recommends that you document phone conversations with patients whenever you make a diagnosis, prescribe or change a medication, direct treatment, or refer someone to another provider or facility. If you don't include such calls in the chart, you open yourself up to several liability risks. One, the patient may claim that you didn't return an important call, and you won't have any way to prove that you did. Two, it will be your word against his if the patient misconstrues what was said in the conversation.

Ideally, the patient's chart should be in front of you while you're talking on the phone, at least during office hours. However, in the event the chart's not available, or you're taking a call at home, use a telephone memo pad. They're typically designed so that one copy goes into the chart while the other remains in the pad, creating a separate chronological record.

6. Flag charts for drug allergies

It's a common practice to put a sticker on a chart if the patient has an allergy or adverse reaction to a medication. But that's not enough, says Lembitz. "You also need to flag charts with "NKA"—no known allergies—if that applies," says Lembitz. "Doctors have assumed that the absence of a flag truly meant the patient didn't have a problem, but that's not always the case, and the result can be a lawsuit."

7. Do chart revisions the right way

Innocent but improper alterations to a chart can make an honest doctor look dishonest. Adding a sentence to a month-old progress note about a clinical finding you omitted may backfire if the patient later sues for malpractice. "The plaintiff's lawyer may spot the alteration and make a big deal about it," says legal lecturer Dan Tennenhouse.

The right way to amplify a progress note, he says, is to write a new one—with the current date—and explain that there was an additional finding from a prior visit. The same kind of transparency is needed to correct an error. Don't resort to a black marker or Wite-Out. Instead, draw a thin line through the words so they're still legible, write the word 'error,' and then date and initial the revision.

And when you first create your note, avoid writing in the margins or squeezing a few words between the lines. "These aren't alterations, but they look like alterations," says Lembitz.

8. Be sure your writing is legible!

It's been drummed into doctors' heads, and rightfully so, that an unreadable scrawl can kill a patient. Fortunately, some doctors appear to be getting the message, says Lembitz—93 percent of practices audited by COPIC in the first half of 2004 met the insurer's legibility standard. "This percentage has been on the rise," he says. "Doctors are achieving legibility mostly through dictation, although some rely on voice recognition software while others have learned to print."

Lembitz notes that only 12 percent of COPIC's insured physicians use an EHR. That means the overwhelming majority of doctors with paper charts have licked the legibility problem.

9. Check the chart before approving refills

You or a nurse may be tempted to refill a prescription for a "good" patient without a chart pull, but don't give in, warns attorney Deborah Willis. She cites this scenario to explain why.

"A longtime patient calls and requests a refill of his Coumadin," says Willis. "The medical assistant authorizes it without pulling the chart. After all, this patient seems to understand his disease and how to manage it. Several days later, he's admitted to the ER with rectal bleeding. He hadn't had a PT test in two months, and the Coumadin dosage was out of whack. A look at the chart would have revealed that this patient needed to come into the office."

10. Master the art of informed consent

Did you perform a procedure on a patient, but there's no signed consent form in the chart, or no doctor's note documenting verbal consent? In the event of a bad outcome, that missing documentation may help persuade a plaintiffs' attorney to take the case, says Willis.

Clearly, informed consent must be documented. However, it's more than a form that a nurse hands a patient. Informed consent is a process, and one that doctors must take seriously. "It's one of the most important things you can do to minimize liability risk," says Tennenhouse. "It deepens rapport with the patient and helps eliminate a sense of surprise if something goes wrong. Otherwise, a patient stunned by a bad outcome may assume that that doctor was incompetent."

Physicians frequently delegate some of the informed consent process to others, such as a nurse who educates a patient about cataract surgery, for example. However, the physician must be the one to sit down with the patient and discuss the risks and benefits of performing a procedure, resorting to alternatives, or doing nothing, say experts. In short, he must obtain the consent.

And the doctor must choose his words carefully so that he doesn't soft-pedal the risks or oversell the benefits, notes Tennenhouse. "You create a false sense of reassurance by saying something like, 'It's a safe procedure and you can expect to do just fine.' It's more realistic to say, 'You can be optimistic. Serious complications are not common.' Likewise, when you prescribe a statin, don't say, 'This will keep you from having a heart attack.' Tone it down to, 'This will reduce the risk of a heart attack.'

"And remember, your employees need training about informed consent, too," he adds. "A medical assistant who says, 'Don't worry—this surgery is perfectly safe' will undermine everything the doctor's trying to achieve."

If your office procedures fall short of the standards set by risk management experts, take a deep breath and tackle the problems one at a time, advises Willis. "Concentrate on one procedure or system each month. You can't do it all at once."

Enlist the support of your office staff. They're part of the problem, but they're also part of the solution, she says. "Employees know where the areas of weakness are, and they're usually very eager to make the office run better."

And don't forget to take advantage of risk-management classes offered by your malpractice insurance carrier. Some are specifically geared toward your employees. Texas Medical Liability Trust, for instance, holds half-day classes for office staff every spring, charging $45 per person. Like many malpractice carriers, the TMLT also will conduct a free risk management audit of a physician's practice upon request. Such audits and classes may even translate into a premium discount.

It's impossible to lower your liability risk to zero, unless you stop practicing medicine. But mastering the flow of information in and out of your office can help reduce that risk to an acceptable level. The devil is surely in the details, but wouldn't you want your own doctor to get the little things right?

Computer tracking system? You probably already have one Your practice management software can help you take charge of clinical data as well as accounts receivable. Some systems include data fields to document orders for tests and referrals to specialists, says computer consultant Rosemarie Nelson in Syracuse, NY. “You enter a date that you expect the test result or consult report to come back,” says Nelson. “When it does, you check it off. You can generate weekly reports showing what tests and consults are still pending.”

Other systems may lack specific fields for patient follow-up, notes Nelson, but they usually have some generic, free-form data fields that you customize for all kinds of tracking purposes. “It’s not hard to do, and you can ask your software vendor for help,” she says.

The managed care module on your system also gives you the ability to produce a list of referrals for which consult reports are pending.

What about making sure that patients come in for follow-up visits six months down the road? Fortunately, says Nelson, most practice management programs include a patient-recall feature. All you do is plug in the time interval. Then you generate weekly reports showing which patients are due for a visit. Some systems automatically print out appointment reminder cards or letters.

While practice management software gives doctors a lot of tracking power, only about one-third of doctors actually exploit these features, says Nelson. “This is an old problem,” she says. “Doctors pay thousands of dollars for software, but then they underutilize it, largely because of poor training.”