Communicating with Patients: Boundary and Risk Issues

Operating a practice, especially your own, is extremely rewarding. Yet once you begin to observe, consult, service and heal patients, new risks apply. And these risks proliferate as you add staff and new patients. As a doctor, risk-management issues should always be at the top of your priority list.

By and large, risk management is the set of processes and procedures enculturated within the practice that ensure reasonable safety, security and confidentiality to the patient. Risk management also identifies, analyzes, evaluates and monitors actual and potential areas of risk associated with patients, always striving toward the prevention of any malpractice and its associated legal actions.

The overarching goal for every office is to promote the safe delivery of high-quality patient care without penalization, injury or accident. Thus, risk management is important not only for you, but also for every one of your staff.

The crux of risk management is culture. It's imperative that you establish principles which rely upon ethical principles incorporating confidentially, compliance and constant communication. The risk taker must concern themselves with future liability, while the compliance maker ensures congruence with all laws, as well as creating a thriving lifelong practice.

Establishing the legacy for good moral judgment requires that each doctor create an environment of trust and respect. Culture utilizes language to bridge this gap, and it is language that controls the relationship. To that end, it is all about communication. Believe it or not, the first instances of patient communication and contact can lend themselves to issues, so it's better to be safe than sorry.

Communication

Laura was shopping in a local grocery store and passed by George, whom she knew as a chiropractor in town. Upon exchanging pleasantries, she stated her neck bothered her; George mentioned his office address and phone number so she could schedule an appointment.

Given insurance and other mitigating health care issues, the better method in terms of risk is for George to state that if treatment is required, Laura should ring his office and schedule something to be evaluated. There should be no promise or exchange of fees. Additionally, George would be better suited by stating that in order to treat Laura, some procedures will be required; an office member can call to explain those requirements, such as "Informed Consent" forms.

The patient has the right to accept or negate any treatment as well as their inherent risks. The doctor must then inform the patient of the type of treatment, the number of treatments, the risks involved, the statistics to support those risks, the risks related to the negation of continued wellness and continued care, as well as any and all fees. Failure to supply this information will get a doctor in trouble.

Once consent is authorized and the doctor treats, he/she must communicate and document all treatments. In as much as the doctor needs to speak, they must record every manipulation without leaving areas blank and without illustrating how the symptom was addressed and the additional treatments required. Record-keeping ensures that both doctor and patient are clearly understanding the issues related to proper patient care, to provide the payee information so the doctor and be properly reimbursed, to aid with any malpractice claims, and to provide a historical record of treatment for future care.

That said, as much as the doctor needs to record, the patient requires understanding. Doctors can quickly become consumed in technical speak and medical mumbo that confuse the patient. Therefore, in order to treat symptoms, all doctors must never "assume" anything and ensure that all patients comprehend all issues related to treatment, such that both parties agree.

Risk With Confidentiality

Every patient you see and treat deserves that all information remain confidential. This is not only the required ethical standard, but also federal law. Most doctors today, because of small offices, have very little storage and file space. However, when patient files are left available for others to see or even appointment sheets have patient names displayed, these all become violations of confidentiality. It is incumbent upon you and your staff to ensure that all patient information remains private.

First and foremost, all patient files should not be placed at the front desk, but rather behind the receptionist or chiropractic assistant so others cannot view them. All files should be placed face down so that the backside is only showing, not displaying patient information / labels. Staff should make this a common practice within their daily routine.

Furthermore, files that are no longer needed for billing and coding should be immediately filed.

Second, there are times when employers, family members and even insurance companies desire to understand a patient's diagnosis. Both staff and the doctor should always err on the side of caution. No patient information should ever be released without the expressed written authorization of the patient. In addition, only copies of the required information should be sent. Never release originals to anyone.

Third, keep in mind we are all human beings. We all enjoy chat and even some rumors. But what this means to you and staff in terms of confidentiality is that at no time should patients' names, diagnoses and information be discussed among family, friends and peers. This is ground for zero tolerance and immediate termination. Patients visit with you to be cured of their symptoms, not to be the target of conversation.

Boundary Issues

Whether or not the doctor is a sole practitioner or has staff is inconsequential when it comes to risk management. In other words, the office must have a culture of confidentiality and adherence to ethical standards. What this means to the doctor can include, but is not limited to:

• Scheduling and rescheduling appointments, and placing those appointments in a confidential file
• Ensuring that every patient has a file, and all paperwork and administrative detail become part of that file
• Making sure every file has a diagnosis, a modality of treatment and the patient's consent for such treatment.
• Ensuring the patient understands his/her obligations to pay, and if billed to insurance, the insurance company's obligation.

When it comes to office management, some cultures and their environments are formal and others informal. Yet there is a gray area when it comes to riddles, jokes, current-event information, political issues, touching, hugging, etc., because as soon as a patient engages with the office and the doctor, there is a relationship. That said, this relationship requires complete ethical and professional conduct.

There are many times when conversations, touching and even implications seem to get out of hand. Boundary issues could be inadvertent, but also tragic. Therefore, every single relationship a doctor has, which includes staff, must maintain professional standards. Anything less and the doctor and the staff will be subject to criminal charges.

To that end, doctors and patients of the opposite sex might want to ensure that a third party remains in the treatment room during the examination. Additionally, jokes, emails, text messages, forums, Facebook and LinkedIn sharing, as well as other forms of social media in the office, must be curtailed. The doctor might also want to install a customer cellphone and computer policy so discussions of sex, religion, politics or other sensitive matters do not take place in the office.

Some of the methods that can be used to ensure proper protocols can include, but are not limited to, a clearly written office procedures manual. This should also include a code of ethics that can be displayed in the lobby or even in every treatment room.

We all understand that sometimes trouble can follow us. With that in mind, a doctor and staff need not accept every patient. Some patients appear more rigid problematic than others. If you fear a problem, do not accept them into the practice. Again, better to be safe than sorry.

To a certain extent, many chiropractors have done a poor job in terms of accepting the inherent risks in practice. Many believe that since treatment is noninvasive, risk is low. That's simply untrue. Knowing, understanding and applying risk-management protocols will help prepare for questions, issues and quite possibly, litigation.

Risk management is similar to an automobile accident. You believe it won't occur until it does. That means prevention is the key. Risk management is about being aware, being proactive, acknowledging and accepting change. Reading voraciously, counseling with others, remaining current and planning are the keys to success. Those who do will thrive; those who decide differently may not be so lucky.