We tend to focus on treatment plans for patient's and the role of the medical assistant in helping the doctor implement his course of action. Yet, how we treat our patient's as consumers may be just as important as how we treat their medical issues.
Risk management in the medical office is about policies in the office that promote the daily use of best practices.. These practices are the one’s that assure the safety of staff and patients; in the daily operation of the medical office.
Best practices for a group or individual physicians are there make sure they are complying with legal standard and ethical standards of the profession. Standard compliance limits the chance of legal liability for the physician. Individual medical malpractice suits can be reduced by office having policies that provide checks and balances in patient care to prevent mistakes. Patient policy should also address patient concerns in a timely manner. This prevents minor issues with patient’s becoming major issues that could result loss of patients or lawsuits.
The change from paper charts to electronic health records is an opportunity for staff to commit to accuracy on a new level.
Source: Wikimedia Commons- NARA
The Devil is In the Details
Minor mistakes in the diagnosis and treatment of patients can lead to law suits. The office manager can not correct mistakes made by the physician in individual patient care , but correct medical record management can reduce errors. Most physicians make decisions based on a review of charts as well as direct patient examination. Poor data gathering on test results, allergies, or past care can result in serious mistakes in patient care. New laws involving patient privacy and patient care require practices update their practices involving patient records. These should mean that medical assistants and all staff involved in adding data or correcting data in patient’s records; should be committed to accuracy.
It is important to know how happy your patient's are with your practice. Using common sense in patient communication can reduce the legal risk your medical office faces.
Some practice risk management is straight forward. Placing signs in waiting areas when floors are wet or simply moping when the practice is closed can reduce this simple type of risk. Patient termination is a bit more complicated.
Practices terminate patient care for a number of reasons. Sometimes it is that the patient has been disruptive or refused to comply with care plans. Many times patients are terminated because the physician can not provide the scope of care needed; and the patient has been unwilling to use referrals from the physician. Sometimes the patient has failed to pay their part of bills for services or keep scheduled appointments.
Most states have laws to cover the ways physicians can terminate the patient physician relationship. You must a have policy in place to comply with these laws. You should provide written notice of termination to the patient within the guidelines. It is also good for a practice to publish notices to existing patients the reasons that the relationship may be terminated. These way patients can be aware if they are acting in ways that may cause them to be dropped from the practice.
Having clear policies for patient scheduling decreases missed appointments and having to charge patients for no shows. Letting patients know the payment options and policies for a practice can reduce the need for practices to dismiss their patients due to unpaid bills. If a referral is made for continuing care the appointment should be made from the current physician’s office. Good communication practices reduce the number of patients who are dismissed for disruptive behavior. Good bed side manner and customer service do a lot to keep patients from becoming frustrated and disruptive.
The practices and policies I have outlined above will reduce the risk of the need to terminate patient relationship. They will also reduce the risk of liability over all for the practice. People are less likely to sue practices where they felt they were treated with respect; they are less likely to leave practice if they fell valued as patients. This is true even if a patient feels a mistake in their health care may have occurred. People are less likely to be disruptive in waiting areas if they are seen in a timely manner. Most patients want to pay their bills on time. They simply need to have their questions answered and payment arrangements made they can manage. The golden rule is still the best way to reduce the liability of the practice overall
These days with the advent of electronic prescriptions,the medical assistant will they are increasingly responsible for dealing with complex prescriptions issues . The dawn of the electronic prescription means more and more of the medical assistant's time will be consumed with prescription related tasks.
This will not only mean submitting prescriptions, but dealing with the problems most medical assistant did not have to deal with, in the good old days of paper prescriptions. Pharmacies will be sending back to your email all sorts of requests. Insurance companies will also send a record number of requests and even alternative prescription suggestions.
Patient's complain to you the drug is not covered.Then you will have to spend endless hours finding out what is on the patient's formulary that is covered. If the doctor is unwilling to allow the change, then you must call the patient. The patient will ask you which pharmacy near their house, charges less for the drug. The patient will expect you to check the discounted drug list of every big box store and grocery in the area to find out who will charge them the least amount of money for their prescription. If you office does not have good prescription management polices; then the wonder of electronic prescriptions will become your nightmare.
As a medical assistant doing a specialty clinical, I saw the process of taking hours to get one prescription filled or renewed ;endlessly repeat itself. This left medical assistance's behind on other duties and patient's frustrated and angry. You are-now responsible for patient drug education of a new kind This is not the kind the pharmacist gives, your patients on drug interactions.This is the kind that tells the patient how they need to take some personal responsibility for this new way of doing prescriptions via the internet.
Many patients simply will not fill prescriptions not covered by their insurance. They put themselves at risk and are inclined to take the problem out on the doctor.They do not understand that they can not wait two weeks to pick up a prescription that has been electronically sent. Many wonder why the prescriptions were not just waiting for them when they show up at the pharmacy two weeks are the prescription was sent by the doctor's office .The patient's are upset that they had to wait at the pharmacy for the prescriptions to be refilled a second time. Patient's need to understand once a prescription shows up electronically at the pharmacy that it will be filled within hours; not days or weeks.
There are many different pharmacies today with large amounts of low cost drugs available for under ten dollars. Yet, the patient whose insurance company will not cover his or her drug; is never at the pharmacy where that prescription is on the five dollar list. They call you to find out where they need to go.
Just A Plan Full of Good Policy Will Make the Medicine Go Down In A Less Stressful Way
So what is the solution? It is a well thought out office policy for dealing patient education and processing of prescription drugs. Below is my attempt at the task. My hypothetical policy will not apply to all types of practices . Most of these rewrites of current office policy should be a shared task among office staff that deal with patient prescriptions .
This office will accept prescription renewals from pharmacies via fax and phone from local pharmacies.
No prescriptions ;which are considered controlled substances or for short term drug therapy will be renewed other than by the patient coming in for an in person visit with the doctor or nurse practitioner.
This office will establish a rotating schedule of Medical Assistants to handle prescription renewals via fax or phone.
There will be a designated phone line that goes to voice mail where patients can call in prescriptions they wish to have called into a local pharmacy.
Patients will be informed on this line that all prescriptions should be called in to the local pharmacy within twenty four hours. If they call on a holiday or weekend the prescription would be called in within 24 hours of the next business day.
Patients must leave the generic or trade name of the drug, the amount taken, doctor's name, and amount of refills on the prescription on the answering machine Patients with incomplete information will not have prescriptions called in. Instead, these patients will be contacted by staff , to get the right information about the prescription.
Every working day the staff in charge of the prescription line will transcribe the recordings They should pull the charts i of the patients requesting refills. It is wise to check to see if your doctor was the original prescribed. It is really not unusual for primary care physicians to write prescriptions originally given by specialist. The doctor may need to review the chart if this situation occurs.. Some doctors will not do this ;unless the patient schedules an appointment to ask the doctor to take over their prescriptions for chronic conditions.
The Medical Assistant will fill out a patient prescription renewal form for each patient.
This form will be returned to the MA ,after physician reviews it. those drugs approved for renewal will be called into the local pharmacy by the medical assistant . This should occur within 24 hours . In cases in which the doctor wishes to review the prescription or change it , MA will call the patient and advise them or the change or review.
Patients who call for drug formularies to be reviewed because a drug is no longer covered ;need to make an in person appointment with the Medical Office Assistant to review their coverage. They must provide new copies of the formulary of covered drugs. Once a list of new covered drugs is complied it will be given to the doctor for review and an appropriate covered drug will be called in. There should be a least a week allotted for this process.
In general generic drugs will be prescribed unless not permitted by the prescribing doctor.
Patients are expected to report problems with prescriptions in a timely manner so the prescription can be changed in a reasonable amount of time.
One parent of minor patients should be in charge of renewing and monitoring their child's prescriptions. The designated parent should be noted in the chart.
In the case of elderly or disabled patients 'who do not handle their own medical affair,s should have a designated contact person for prescription related issues noted in their chart.
All patients in this practice who take prescriptions for chronic conditions will have a yearly prescription review by the doctor or nurse. They need to keep this appointment to be eligible for prescription renewal by phone or fax after the initial twelve month period.
Patient Education :
All medical assistants are expected to have a base knowledge of drugs frequently prescribed in this practice and their potential hazard of use.
The practice will have consumer drug information sheets containing basic information about common drugs or classes of drugs prescribed in this practice.
Medical Assistants will discuss with patient's information about new prescriptions.
Medical Assistants will emphasize drug interactions with herbal or over the counter drugs regardless of if the patient admits using them.
Medical Assistant will emphasize the need for medication compliance. They will discuss issues that might cause patient non compliance.
Medical Assistant can demonstrate inhalers and the use of insulin pins if the patient or their care taker requires such instruction.
Patients will be advised to report good changes and bad changes in their condition once they have started a prescription drug. They should always call the office with drug concerns.
Patients should be encouraged to read prescription inserts and ask their pharmacist questions about their medication.
Patients are to be instructed to call the office before adding other prescriptions or OTC to their drug routine. Patients not complying with this policy may lose their right to have prescriptions renewed by phone or fax.
Symbol Table for Non Verbal communication with patients (Photo credit: Wikipedia)
A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)
Medical Assistants in most practices either spend more time
with patient or a least a comparable amount of time as the physician or nurse practioner.
It is essential that the medical assistant have effective communication skills
and avoid roadblocks to communication. This can be called developing
therapeuticcommunication skill.
This applies to medical assistants throughout the practice.
Front desk and billing medical assistants also have significant amounts of
communication with patients. The attitude of the whole staff will affect the patient’s
attitude towards the practice and treatment compliance.
Sometimes when patients make appointments the medical
assistant who schedules the appointment must play detective. Is the patient
really calling to be seen for what they say? Is the patient calling to discuss
a matter that is an ongoing medical concern that could be addressed by a phone
call? Is the patient experiencing a medical event that requires a same day
appointment? Is a care giver calling for advice and is not sure if they need to
bring the patient in? This an the recent changes in managing prescriptions
electronically and in healthcare will leave the simple task of scheduling appointments
into one where you will have to have very good communication skills in order to
service the patient’s need’s and direct their call appropriately.
Those who work in billing are also going to be bombarded
with insurance questions related to the Affordable Care Act. You will be
getting patients who are not sure what preventative services is cover or who
have never had insurance before and do not understand concepts like what a
co-pay or deductible is.
You may have had additional training to deal with the
patients, but you must learn how to communicate complex insurance ideas to the
patient. Especially, patients who do not understand their bill under this new
system, might have a think their billing is being mis-managed.
What is Therapeutic Communication?
Therapeutic communication is that which expresses empathy
for the patient. It is best when discussing events that may be traumatic to the
patient, but should be used in the course of communication with the patient as
it falls in to the area of best practice.
Therapeutic communication is that which puts the patient at
ease and elicits the answers needed to provide the best patient care. It is not
medical lingo. It is translation the diagnosis, treatment protocol, and prognosis
into language the patient can understand. It is a way of managing the interview
and educational discussions with the patient that lowers their stress level. An
increased stress level in a patient can cause them to use self defense
mechanism that block clear communication and make your job as an effective
medical assistant much harder.
Things to be aware of when seeking to use Therapeutic
Communication with a Patient
We all have personal bias and prejudices that may influence
how we interact with a patient. If we believe that an older patient suffers
from dementia we may disregard their expressions of concern of discomfort. We
may believe that a patient with a questionable immigration status can not
access the practices system of care. These are not your issues. You must first
and always address patients personally and with concern. Ask and record the
elderly patient’s responses to the best of your ability.
Address them with the
same respect regardless of the appropriateness of the response. Then address
their care giver for clarification. This approach takes more time but it is the
best way to establish the most productive relationship with the patient. In
regard to a patient’s ability to pay, only inquire about such issues if the
patient asks about financial arrangements. Then refer them to the appropriate
source. Medical assistants who work in billing will have much better chance of
explaining all the options with the patient. if they have not left the exam
room feeling insulted by your inquiries about their insurance coverage status.
These are just two examples. To avoid your personal produces
and bias, simply apply the golden rule and put forth a positive attitude. This
does not mean to be Pollyanna, but to be pleasant and straightforward and to be
committed to treat every patient with the attention and respect they deserve.
Patients come with their own set of bias and prejudices.
Part of therapeutic communication is to not personalize the patients expression
of these beliefs. Again many older patients may not have had the experience of
cultural diversity that younger patients may have had. If they seem to be
uncomfortable with your race, ethinic background or sex. As a professional
medical assistant you must simply have
to over look it. Medical assistants are not the moral police. If a male elderly
patient is uncomfortable with a male medical assistant or visa versa then politely agree get one in the exam room.
You may have to ask the patient to wait longer or
reschedule, and if anger on their part erupts, use the skills you have to diffuse
the situation. Apologizing for the incontinence and giving alternatives goes a
long way. Also make sure you politely restate the patient’s request. Do not
reprimand or insult a patient for expressing negative stereotypes, simply hand
the situation and make notes about the patient’s preferences without comment on
your opinion. Difficult people need access to medical care too and their
positive interaction with you may diffuse some of their fear of cultural
diversity
The basics of therapeutic communication
This hub can only cover the generalities of therapeutic
communication. First you must be able to successfully evaluate the patient’s
mood. In the case of a routine exam with a patient that has been to the
practice the patient is probably pretty emotionally neutral or pleasant if they
have a positive relationship with the practice. They will have positive facial expressions
and open body language. Open body languets means that they will be relaxed and
their arms will not be crosses. In general they will appear open and not under
stress. They will engage in pleasantries and chit chat. These of course are the
patient’s that we find easiest to deal with. It is easy to reflect the
patient’s mood back to them. There is congruency in the communication because
the patient knows what to expect and is not expecting any surprises.
In this type of patient interaction it is best to keep the pleasantries
to a minimum to keep the patient focused at the task at hand. If the patient
seems to be in somewhat of a hurry or anxious about the length of a check up ,
it is best to restate and inquire about that concern and give them a realistic
time frame , remind the patient that the doctor might end up taking longer
because he or she is giving everyone the best attention possible.
You also will have to update patient information in a way
that may require that you ask questions that the patient feels they have
already answered. Again, simply state this is part of the task and empathizes
with them having to repeat so much information.
If something serious is found in check up, it is important
that you reflect hat you understand the patient’s concern. Again be congruent
in your Reponses. If the doctor is sending the patient for more tests be sure
to reassure the patient that the doctor is doing what is routine in the case of
an unseal finds in the routine exam. Be sure to give the patient all the
information they need including the way and the time it will take them to get
the test results. Showing genuine concern and empathy for what may be an
unexpected serious medical concern with influence the ongoing treatment of this
patient. This is what therapeutic communication tries to achieve the best
patient comfort level possible under the circumstances that will assure the
best patient compliance with testing and treatment
Patients new to the practice will have varying degrees of
anxiety. First impressions count so put your best communication skills forward.
Make it therapeutic communication from the moment you meet new patients. Empathize
with starting with a new doctor. Be honest about the length of appointments. If
you work the front area make sure you give the practice policies other than
just the privacy notice. Ask if the patient has questions or concerns about
being a new patient. If the patient is having difficulties getting records transferred
make the extra effort and offer to fax needed forms for them. The practice can
not serve the new patient’s needs without a complete medical history.
If patients have filled out long patient histories in the
waiting room, tell them in advance they may have to clarify questions they have
already answered.. Use your most effective summary skills and restatements to
get the information you need in the least amount of time. Inquire again in the
exam room about any concerns or resources the patient might need to know when
becoming a new part of your practice. Getting off on the right foot will help
you have a productive and pleasant relationship with the new patient for years
to come.
If you work with specials populations like the elderly or children
then you will need to have additional skills in order to engage in therapeutic
communication. In general you show respect for elderly patients with the
understanding that reduced vision, hearing, or cognitive issues may require you
exercise more patience. A medical assistant can not get frustrated when questions are not
understood by an elderly patient.
It helps to have some basic knowledge of child development
to speak effectively with children. Questions and statements should always be
directed toward the child first and the care giver secondly as much as possible.
Obviously, with very small children you must be able to surmise non verbal
communication of the child in addition to what their care giver is telling you.
Special practices such as oncology and hospice require knowledge
of therapeutic communication with in the context of crisis and grief. Today
cancer is not a death sentence for most but a struggle that puts huge financial,
emotional, and physical stress on the patient and all of their family. The
ability to empathize and be a support for the patient first and secondarily to
the care givers is important. The length of cancer treatment means you will be
dealing with the patients on a regular basis for an extended period of time.
Therapeutic communication that encourages absolute adherence to treatment protocols
is essential. This is especially true if for the patient the illness seems less
painful than the treatment. Understanding that patients will become
uncooperative and depressed during the course of therapy is essential, giving
moral support and showing that you understand can help resolve issues of
noncompliance.
Patients who face end of life issues and their family need
specialized forms of therapeutic communication that may require you to study
skills outside the context of normal medical assisting communication.
In the end therapeutic
communication with patients
becomes the normal way you interact with all patients. Dealing with patients in
crisis situations can take a toll on your emotional health and communications
within your personal life. Make sure that your have a support system and a
method to manage your stress as a health care provider.
Vaccination Every Morning (Photo credit: madam3181)
English: Night at the Doctors office (Photo credit: Wikipedia)
Patient: Doctor, I don't feel well and I'm not sure why (Photo credit: DES Daughter)
A patient having his blood pressure taken by a physician. (Photo credit: Wikipedia)
Dealing with difficult patients is something that when we train to be medical assistants gets over looked. We have course in professionalism which many assume eliminate the problem. We are not always the source of anger or misunderstanding that our patients display. If is wise to have an office policy in place that gets everyone on the same page when it comes to our approach to deal with difficult patients. I would divide most difficult patients into two groups; front office and exam room. Here I will deal with the difficult patient in the front office.
The front office difficult patient is one who is often upset with staff about scheduling, billing, and prescription refill issues. Many times these are patients who do not understand that their insurance does not give them a totally free ride when it comes to care. When they get the bill for their portion of care they are usually convinced the office billed their insurance wrong. Sometimes they suffer from sticker shock when they see the amount of their co pay that has accumulated when they have had a condition that required numerous office visits. The patient who is suffering from medical bill sticker shock can be dealt with. First it helps to have someone doing the billing in the office that is willing to talk to patients about their financial responsibility. If a patient has a forty dollar co pay for an office visit and their treatment is going to require several follow up visits they need to be informed. It is simply best practice to collect the co pay upfront so the bill does not become exorbitant in the first place. New patients should not just be handed an office payment policy.
They should be verbally informed that payment is expected at the time of service for their co payment. If patient’s have questions about how much of their treatment is covered by insurance, someone in the office should be willing to help them find out. Since we do not have crystal balls and can not predict how well treatment will go, we need to emphasize that it is only an estimate. Ultimately, it is the patient’s duty to deal with their financial obligations to the practice. Most patients new or established will not admit when they are in financial difficulty. They wish to keep such matters private until they are unable to pay their bills.
Again, if your office offers financial arrangements for patients who are going to have default paying their share of the bill they should know about this policy before they need it. Discussion of a patient’s financial hardship should take place in a private setting and only staff that does the billing needs to be aware of their circumstance. The financial health of a patient should be guarded information just as their medical information is. The patient that is upset about scheduling is many times an established patient.
.
They may have been in the practice when it was relatively new or had more staff. They became used to being able to have a wide variety of choices when it to seeing the doctor or nurse fractioned. They also may feel entitled to see the doctor when they want because they have been loyal to the practice. This patient needs to be told that all patients are accommodated the best way possible when they call for an appointment.
They also may need to be reminded that those with serious conditions are seen sooner then those patients who are being seen for routine matters. It helps to thank these patient’s for their patience and offer to really work to schedule them at the next most convent time for them. You will not always win this battle as some people because of social position are catered to by their hair dressers, mechanics, and other service professionals.
They simply will not understand that the doctor’s office is not in the business of catering to the busy professional schedule. In this case you may recommend a walk-in or urgent care clinic in case this patient’s will not give up their insistence on being seen immediately. This action should not be taken with out consulting the health fractioned first. You also may have the option of offering these patients the opportunity to see another doctor in the practice with a more open schedule. Patient’s that are upset about prescription issues again should receive a copy of the office policy in regard to refills.
If they call a dedicated line for refills they need to know that you will take at least one business day to respond. If they insist on refills on a medication that has expired, they need to understand they may need to come in and see the doctor in order to have the prescription renewed. You have to stand strong on your practices policy. This is especially true in regard to controlled substances. Many states have strict regulations that must be followed when dealing with the class of drugs.
Lastly, electronic prescriptions and changes in drug formularies are issues you have little control over. You should always advise a patient to wait 24 hrs and call the pharmacy to see if an electronic prescription has been filled. You should encourage patients to put long term prescriptions on automatic refill. You can call on patient’s behalf if they have issues getting their electronic prescriptions filled, but as long as you have done it right on your end there is little you can do about the speed at which the pharmacy on the other end. Most doctors will change a prescription to something covered by the patient’s insurance, but it is the patient or their care takers job to find out what prescriptions are covered and which are not. Sometimes for medical reasons an doctor will petition the insurance company to cover a certain drug, but this is a cumbersome process and can not be done for every patient.Communication is the best way to avoid angry or frustrated patients in the front office
. You should always be respectful and honest about the things you can and can not help the patient with. Most people will calm down and do their part to solve the problem if you are clear on what you can do to help them deal with their particular issue.
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