Understanding Professional Liability Risks of Record Management

Understanding Professional Liability Risks of Record Management

A paper or electronic patient health care information record serves two major purposes: communicating information both within and outside the practice and creating written history in the event of later questions or challenges. Complete, accurate, and legible health care information records document all phases of medical treatment, including the care plan, laboratory and diagnostic testing, procedures performed, and medication provided.

The new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) analyzed 287 closed professional liability claims against nurse practitioners (claims that resulted in an indemnity payment of $10,000 or greater) over a 5-year period. The report’s analysis revealed that the majority of claims against NPs resulted from an alleged failure involving core competencies, and demonstrates that nurse practitioners are responsible for reviewing, following up on, and documenting the results of appropriate tests and consultations in a timely manner.

The following general principles of documentation can help the practice maintain a consistent, professional patient health care information record:

  • Ensure that hard-copy notes are legible and written and signed in ink, and also that they include the date and time of entry.
  • Avoid subjective comments about the patient or other health care providers.
  • Correct errors clearly by drawing a single line through the entry to be changed.
  • Sign and date the correction, as well as the notation giving the reason for the change.
  • Do not erase or obliterate notes in any way. Erasing or using correction fluid or black markers on notes may suggest an attempt to purposefully conceal an error in patient care.
  • Document actions and patient discussions as soon as possible after the event. If it is necessary to make a late entry, the entry should include the date and time, along with the statement, “late entry for ______” (i.e., the date the entry should have been made).
  • When dictating notes, include all vital information, such as date of dictation and transcription. Sign transcriptions and write the date of approval or review.
  • Never alter a record or write a late entry after a claim has been filed, as this may seriously compromise legal defense.
  • Develop a list of approved abbreviations for documentation purposes. Review and revise the list as necessary and at least annually. In addition, maintain a list of error-prone abbreviations that should never be used, such as this one from the Institute for Safe Medication Practices.
  • If using a form, complete every field. Do not leave any lines blank.

Furthermore, to help nurse practitioners avoid this segment of risk, nurses should ensure their practice has a written policy governing documentation issues, and all staff members are trained in proper documentation practices. The policy should address, among other issues: health care information record contents, patient confidentiality, release and retention of patient health care information records, and general documentation guidelines.

And while rare events may be difficult to prevent, nurse practitioners can glean lessons from the experiences of their colleagues to help evaluate and enhance their own patient safety and risk management practices.


Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.

Informed Consent and Informed Refusal in Managing Patient Expectations

Informed Consent and Informed Refusal in Managing Patient Expectations

Insights from the new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) show that the majority of claims against nurse practitioners developed from a failure involving core competencies, such as diagnosis, medication prescribing, or treatment and care management. Allegations related to failure to diagnose and improper prescribing/managing of controlled drugs occurred most frequently.

What the report also found was that in many claims, the nurse practitioner met the standard of care, but the patient was nonetheless dissatisfied, often due to a lack of communication or understanding. The informed consent discussion represents the first step in managing patient expectations, thus reducing the possibility of a misunderstanding and mitigating the risk of a consequent lawsuit.

Additionally, documenting the informed consent process provides the best defense in the event a patient alleges that the proposed treatment, other options, or the potential for injury were not adequately explained to them. Refer to state statutes for guidance on the informed consent process, as there is considerable variance among states. This is especially true when it comes to caring for minors or cognitively impaired patients, and emergency situations.

The informed consent process involves two main components:

  • Discussion, providing the patient with sufficient information about and time to consider:
    • The nature of the proposed treatment, including rationale, anticipated benefits and prognosis.
    • Alternatives to the proposed treatment, including specialty referral options or no treatment at all. This should also include an explanation of why, according to one’s professional judgment, the recommended treatment is preferable to alternatives.
    • Foreseeable risks, including potential complications of the proposed treatment and risks of refusing it.
  • Documentation of the discussion and the outcome of the discussion in the healthcare information record, which often includes the use of a written informed consent form in addition to the verbal component.

The informed refusal process is similar to, but goes beyond, the process for informed consent. Refusal of care increases the potential liability exposure for the nurse practitioner, but nurse practitioners can help minimize their liability exposure by being aware of their consequent responsibilities and documenting the informed refusal process.

Nurse practitioners who continue caring for a patient after they decline treatment recommendations must be aware of their responsibility to:

  • Continue to examine and diagnose the patient for the duration of the practitioner-patient relationship and as long as the patient continues to refuse treatment.
  • Continue to inform the patient about the condition and its associated risks, while the practitioner-patient relationship is in place, the condition exists, and the patient continues to refuse treatment.
  • Continue to inform the patient how their refusal of treatment may affect treatment of other conditions or problems, when discussing these conditions.

After discussing the potential consequences of refusal with the patient, nurse practitioners should complete a comprehensive progress note and document the refusal using a written form, which should be incorporated into the patient health care information record. Progress notes should document:

  • The individuals present during the discussion.
  • The treatment discussed.
  • The risks of not following treatment recommendations, listing the specific risks mentioned.
  • The brochures and other educational resources provided.
  • The questions asked and answers given by both parties.
  • The patient’s refusal of the recommended care.
  • The patient’s reasons for refusal.
  • The fact that the patient continues to refuse the recommended treatment.

As the data proves, it is imperative for nurse practitioners to protect their patients and their practice by documenting all phases of medical treatment, discussing (and documenting) the nature of all proposed treatments with patients as well as educating them about the need for follow-up, and signs and symptoms that should prompt a follow-up call.

In addition, today’s nurse practitioners must continuously evaluate and enhance their patient safety and risk management practices by remaining current regarding their clinical practice, medications, biologics, and equipment utilized for the diagnosis and treatment of acute and chronic illnesses and conditions related to one’s specialty and obtain regular continuing education.


Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.

Risk Recommendations for Medication Management

Risk Recommendations for Medication Management

Prescribing is not a responsibility to be taken lightly. Prescribing a drug to any person – even as a “one-time favor” for a coworker, relative, friend, or neighbor – establishes a patient-practitioner relationship. Prescribe the right drug, for the right patient, in the right dose, by the right route, at the right times, for the right duration, and for the right indications.

As health care delivery has continued to evolve, many Americans are using nurse practitioners for much of their health care needs, making NPs a critical component of the modern system. This growth in demand and responsibility has also increased and evolved the many risks NPs face in their work environments.

The Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) took a deeper look at those risks by analyzing 287 closed professional liability claims against nurse practitioners (claims that resulted in an indemnity payment of $10,000 or greater) over a 5-year period.

Five allegation categories accounted for 95% of all the closed claims in the analysis: diagnosis, medication prescribing, treatment and care management, assessment, and scope of practice. A detailed view of the allegations related to medication prescribing/management show that within this category, the top three allegations involved improper prescribing or management of controlled drugs (27.7%), improper management of medication (24.7%), and wrong dose (15.4%).

The following strategies can help nurses reduce the likelihood of drug-related errors:

  • Review current allergy information.
  • Learn about medication allergies, side effects and interactions, including how to screen patients for potential allergic or other adverse reactions, recognize an allergic response, and treat serious reactions.
  • Review previous medication orders alongside new orders and care plans, and resolve any discrepancies each time a patient moves from one care setting to another.
  • Use developed standard order sets to minimize incorrect or incomplete prescribing, standardize patient care, and clarify medication orders.
  • Emphasize the importance of keeping follow-up appointments, especially when the patient is discharged on warfarin or direct oral anticoagulation therapy and there is a transition of care process.

Nationwide, the Centers for Disease Control and Prevention (CDC) reports that overdose deaths related to prescription opioids were five times higher in 2016 than 1999. Nurses can play an important role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients.

When prescribing opioid drugs:

  • All patients suffering pain should be given a thorough physical and have a history taken, including an assessment of psychosocial factors and family history. Reevaluate the level of pain and the efficacy of the treatment plan at every visit.
  • Conduct an opioid risk assessment and depression scale test before prescribing opioids and perform periodic screening thereafter.
  • Use an appropriate opioid dose based on patient age and opioid tolerance.

These claims and recommendations demonstrate the importance of the responsibility for properly evaluating each patient prior to prescribing, following up, and documenting the results of appropriate tests and consultations in a timely manner. While rare events may be difficult to prevent, nurse practitioners can glean lessens from the experiences of their colleagues to help enhance their own clinical, patient safety, and risk management practices.


Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.

Nurse Practitioners and Today’s Professional Liability Risks

Nurse Practitioners and Today’s Professional Liability Risks

According to the American Association of Nurse Practitioners, there are more than 234,000 nurse practitioners (NPs) licensed in the U.S. today. As health care delivery has continued to evolve, many Americans are using NPs for much of their health care needs, making nurse practitioners a critical component of the modern system. This growth in demand and responsibility has also increased and evolved the many risks NPs face in their work environments. The new Nurse Practitioner Claim Report: 4th Edition from CNA and Nurses Service Organization (NSO) took a deeper look at those risks by analyzing 287 closed professional liability claims against nurse practitioners (claims that resulted in an indemnity payment of $10,000 or greater) over a 5-year period. Study results found the average total incurred payment per claim was $240,471, and indicated that while the number of nurse practitioner claims have been relatively stable over the past five years (2012-2016), the average indemnity payment has increased at least 2% annually since 2012.

Current Liability Patterns and Trends

Nurse Practitioner Claim Report insights show that the majority of claims against NPs developed from a failure involving core competencies, such as diagnosis, medication prescribing, or treatment and care management. Allegations related to failure to diagnose and improper prescribing/managing of controlled drugs were found most frequently.

These claims demonstrate that nurse practitioners are responsible for reviewing, following up on, and documenting the results of appropriate tests and consultations in a timely manner, as well as properly evaluating each patient prior to prescribing medications.

Other findings from the report revealed:

  • The three specialties with the highest average paid indemnities were neonatal, women’s health (obstetrics), and emergency medicine.
  • The highest percentage of closed claims occurred in the adult medical/primary care, family practice, behavioral health, and gerontology specialties.
  • The health care delivery settings that experienced the greatest number of claims were physician office practices, nurse practitioner office practices, and aging service facility, skilled nursing.
  • Both the frequency and severity of nurse practitioner office practice setting closed claims have increased significantly. In 2012, this setting accounted for 7.0% of the closed claims, with an average paid indemnity of $45,750. In 2017, this setting accounts for 16.4% of the closed claims, with an average paid indemnity of $158,611- three times greater than in the 2012 report.
  • Five allegation categories accounted for 95.0% of all the closed claims in the analysis: diagnosis, medication prescribing, treatment and care management, assessment, and scope of practice. Diagnosis-related claims had the highest percentage of closed claims, accounting for 32.8% of all closed claims and with an average paid indemnity of $283,263 per claim.
Current License Protection Patterns and Trends

Different from a professional liability claim, an action taken against a nurse practitioner’s license to practice may or may not involve allegations related to patient care and treatment provided by the nurse practitioner. The Nurse Practitioner Claim Report also evaluated this particular risk area, analyzing 404 reported license protection claims affecting CNA/NSO-insured NPs.

Of the closed claims, 240 resulted in a license defense cost in which legal counsel defended nurse practitioners against allegations that could potentially have led to license revocation. The allegation classes with the highest percentage of license protection defense paid claims were medication prescribing/management (27.1%), scope of practice (22.1%), treatment and care management (13.3%), and professional conduct (8.8%). The average payment – comprising legal expenses, associated travel costs, and wage loss reimbursable under the policy – was $5,987. License defense paid claims involved both medical and non-medical regulatory board complaints against nurse practitioners.

Risk Control Recommendations

While rare events may be difficult to prevent, nurse practitioners can glean lessens from the experiences of their colleagues to help enhance their own clinical practices. The following selection of basic risk control recommendations can serve as a starting point for nurse practitioners seeking to evaluate and enhance their patient safety and risk management practices.

  • Remain current regarding clinical practice, medications, biologics, and equipment utilized for the diagnosis and treatment of acute and chronic illnesses and conditions related to one’s specialty and obtain regular continuing education.
  • Document all phases of medical treatment, including the care plan, laboratory and diagnostic testing, procedures performed, and medication provided in a timely and objective manner. The substance of all electronic communication related to patient care, including diagnostic test-related communications – whether by telephone, text, email, or instant messaging – should be documented in the patient health care record.
  • The informed consent discussion represents the first step in managing patient expectations. Discuss (and document) the nature of proposed treatment, alternatives to the treatment, and foreseeable risks and benefits of the treatment options.
  • Also engage in an informed consent discussion with patients when prescribing medications. Educate the patient about the need for follow-up, and signs and symptoms that should prompt a call to the doctor or a trip to the emergency department.

A self-assessment checklist also is available in the full report to inspire nurse practitioners nationwide to examine their practices carefully.

In Summary

This analysis reveals that, while there have certainly been advances in clinical practice and patient safety, many claims continue to develop. It demonstrates that nurse practitioners are expected to diligently screen, test for, monitor, and/or treat diseases known to have high morbidity and mortality rates and are responsible for obtaining appropriate tests, consultations, and referrals to meet the patient’s medical needs. The report findings also reinforce the responsibility that nurse practitioners must prescribe the right drug, for the right patient, in the right dose, by the right route, at the right times, for the right duration and for the right indications.

Armed with this insight, nurse practitioners can apply key risk control recommendations and resources to focus their efforts on areas of statistically demonstrated error and loss.


Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management, or legal advice. It is not intended to be a substitute for any professional standards, guidelines, or workplace policies related to the subject matter.

This risk management information was provided by Nurses Service Organization (NSO), the nation’s largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to [email protected] or call 1-800-247-1500. www.nso.com.

Breaking Barriers to Patient Compliance

Breaking Barriers to Patient Compliance

Despite a nurse’s best efforts, some patients aren’t willing to follow instructions, but the impacts of patient noncompliance are too serious to ignore.

Prescription drugs provide an excellent example of the importance of adherence. It’s estimated that up to 30% of prescriptions go unfilled and as much as 50% of medications for chronic disease are not taken as directed according to a study published in Annals of Internal Medicine. The study’s authors go on to say that failure to follow prescriptions causes about 125,000 deaths per year and up to 10% of hospitalizations.

Nurses can enhance patient understanding of and adherence to their overall treatment plans by strengthening communication, rapport, and education.

It Starts with Communication

Asking the right questions and opening the lines of communication between patient and nurse can uncover critical barriers to treatment compliance.

  • Pose questions in a constructive, problem-solving manner. For example, “I see that you have not been completing your daily exercises. I wonder if they are causing you too much pain, or if there is some other reason?”
  • Try to relate personally to the patient to build a stronger therapeutic partnership. Get the patient to express what the nurse and care team can be doing to help them better meet their personal health goals.
  • Set and adhere to a discussion agenda for every encounter. Begin with a discussion of the patient’s personal goals and issues before moving on, such as “First, tell me what concerns you most, and then we’ll discuss test results.”

Encouraging Cooperation and Participation

Explain to patients that they must take some responsibility for the outcome of their care and treatment. Let them know that everyone caring for them wants them to be successful in regaining their health. If barriers to compliance persist, try asking the patient what he or she believes would be more effective. The goal should be to achieve a mutually acceptable care plan.

  • Clearly and explicitly convey the severity of the problem and the risks of not properly carrying out instructions. Give the patient an opportunity to ask questions and clarify the instructions.
  • Find out if there are any underlying factors affecting compliance. For example, “It sounds as though you may be concerned about the medication’s possible side effects. Is that why you have not taken it as prescribed?”
  • Identify any practical or logistical difficulties that may hinder compliance.
  • End each encounter by having the patient verbalize at least one self-management goal.

Enhancing Patient Education and Understanding

Key barriers to communication – such as low health literacy, cognitive impairment, or limited English – need to be assessed early on to help uncover the best solution for successful communication.

  • Have access to qualified and credentialed interpreters for use when necessary.
  • Ask patients if they have any questions about their medications and ask that they describe in their own words how to take them.
  • Consider involving a health coach, health navigator, and/or case manager for the patient.
  • Ask patients to repeat critical instructions and paraphrase in everyday words the medical information they have been given.

Helping Patients Manage Logistics

Sometimes a patient’s noncompliance issue is out of their hands due to a lack of personal support at home or financial restraints. Uncover where those patients are struggling:

  • Do health care information records note who can help your patient when they’re outside of the health care setting? Do they have the consistent help of a spouse, relative, friend, or paid caregiver to aid with their care?
  • Are patients asked whether they can get to appointments via car or public transportation, and are responses documented in the patient care record?
  • If a patient lacks the physical or mental capacity to perform such essential tasks as changing dressings or picking up prescriptions, has a relative or friend been asked to assist, with the permission of the patient or legal guardian?
  • Does the patient lack the financial resources to comply with their current care plan? Are they concerned about the out of pocket costs for treatment, or having to take time off of work?
  • Document these concerns in the patient care record, and work with the patient and their primary care provider (with the patient’s permission) to find solutions.

Supporting the Effort with Documentation

To help staff deal with hostile, manipulative, or uncooperative patients, written protocols should be in place to help all staff respond to and deal with difficult patients. This should include ways to document and procedures for such common concerns as:

  • Repeated prescription refill requests of questionable nature
  • Narcotic use and general pain management in drug-seeking patients
  • Appointment or procedure cancellations
  • Unacceptable behavior, such as belligerent voicemail messages or yelling or cursing at staff
  • After-hours patient calls
  • Refusal to consent to recommended treatment
  • Neglecting to take medications, do exercises, or make necessary lifestyle changes
  • Terminating the patient-provider relationship

Monitoring Compliance

Driving patient compliance often means health care teams need to repeat themselves again, and again, and again. Different tools and strategies can help nurses drive compliance.

  • Remind patients of upcoming appointments, including referrals and laboratory visits, via telephone and/or email.
  • Try electronic alerts to remind patients with a history of noncompliance about screening and monitoring requirements.
  • Inform blind or visually impaired patients of subscription services that use wireless devices to deliver reminders to take medications or perform vital self-care activities.
  • Schedule follow up and referral appointments before patients leave the facility.
  • Document no-shows and conduct telephone follow-up within 24 hours.

Know if there is a written policy for terminating the patient-provider relationship if the patient is chronically noncompliant and fails to respond to reminders and other messages.

Keep at It

Patient noncompliance is a deep issue with no easy answers or simple solutions. Nurses in almost any setting will encounter noncompliant patients, but with consistent communication and a persistent, but cooperative, spirit nurses can work to overcome the risk of noncompliance one patient at a time. Nurses also can explore Nurses Service Organization’s patient self-assessment checklist to help facilitate open communications.


Disclaimer: This article is provided for general informational purposes only and is not intended to provide individualized business, risk management or legal advice.  It is not intended to be a substitute for any professional standards, guidelines or workplace policies related to the subject matter.