TMLT risk management staff conduct on-site practice reviews to help physicians determine and address their medical liability risks. In 2016, risk managers reviewed more than 2,000 physician practices, and gave the following 10 recommendations most frequently.

1. What every physician
needs to know:
top 10 risk management
recommendations

2. about
• TMLT risk management staff conduct on-site practice
reviews to help physicians determine and address their
medical liability risks.
• In 2016, risk managers reviewed more than 2,000
physician practices, and gave the following 10
recommendations most frequently.

3. 1 document after-
hours calls
• Documenting after-hours calls and any instructions
given to patients is important for continuity of care.

4. 2 EHR policies
& procedures
• The practice should maintain up-to-date, written
policies for EHR processes. Policies may include
privacy and security risk analysis, privacy and security
training for staff, and other protocols to protect health
information.

5. practice policies
& procedures3• Keep a current policy and procedure manual for patient
care. The manual should include information on
communicating with patients, medication refills, order
tracking systems, missed appointments, and emergency
protocols.

6. 4 document names
of others
• It is important to note who is present during a patient
visit because important instructions and education
regarding the patient’s assessment and treatment are
discussed.

7. edit pre-
formatted text5• When using pre-formatted text or templates in EHRs,
edit entries to ensure the record accurately reflects the
clinical care delivered. Inconsistent or contradictory
information in the record — due to default text or
cloning of information from other visits — could lead to
errors.

8. document follow-
up requests
• It is important for the continuity of care to document
when a patient should return for a follow-up visit.
This enables office staff to schedule the visit and may
prevent the patient from falling through the cracks.
6

9. review and update
medications
• Prescription and over-the-counter medications should
be reviewed and updated in the record at each visit
to monitor compliance and help prevent adverse drug
reactions. New patients should be encouraged to bring
all current medications to the initial visit.
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10. 8 have a tracking
system in place
• When patients are referred to specialists or to an
outside source for lab or diagnostic tests, a tracking
system can ensure the patient is seen and the results
are received and reviewed.

11. document patient
phone calls
• Document patient phone calls and any instructions
given to patients. As with the documentation of after-
hours calls, this information can help the physician and
subsequent caregivers in treating the patient.
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12. document
diagnostic
reports
• Documenting the physician’s review of consultant
reports, diagnostic results, or outside tests
demonstrates that the results were seen in a timely
manner. When appropriate, document the action taken
on specific results and the physician’s rationale for
those actions.
10

13. protection for
a new era of
medicine
about tmlt:
With more than 20,000 health care professionals in its care, Texas Medical
Liability Trust (TMLT) provides malpractice insurance and related products
to physicians. Our purpose is to make a positive impact on the quality of
health care for patients by educating, protecting, and defending physicians.
www.tmlt.org
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