Risk Control Recommendations

Question

Answer

Risk control recommendations for therapists include: 

• Know and comply with your state laws regarding the scope of physical therapy practice. Therapists are responsible for knowing and understanding the regulations governing the practice of physical therapy in each state where they practice, as well as the policies and protocols of their employers and the facilities where they provide services.
• Follow referring practitioner's orders. If orders are ambiguous or unclear, contact the practitioner to clarify orders and document any changes and conversations with the practitioner in the PT healthcare record. 
• Recognize patients’ medical conditions, comorbidities, and any additional specific risk factors that may affect therapy. Notify the appropriate practitioner(s) of the patient’s clinical responses to therapy, and swiftly convey any signs or symptoms of physiological or psychological changes that could indicate a new pathological condition or a change in an existing condition.
• Document your patient care assessments, observations, communications, and actions in an objective, timely, accurate, complete, appropriate, and legible manner. 
• Never alter a record for any reason or add anything to a healthcare record after the fact unless it is necessary for the patient’s care. If information must be added to the record, accurately label the late entry. However, never add anything to a record for any reason after a claim has been made. If additional information related to the patient’s care emerges after becoming aware of pending legal action, discuss the need for additional documentation with your manager, the organization’s risk manager, and/or legal counsel.

Risk Recommendations for providers include:  

• Perform at least annual performance reviews for each employee, including a review of errors, “near misses”, document requirements compliance, existing skills and directly observed competencies.
• Provide physical therapy staff with coaching, mentoring, and clinical and system education as needed to ensure that patient safety requirements are satisfied.
• Ensure that clinical practices comply with standards endorsed by physical therapy professional associations, state practice acts, and facility protocols.
• Provide appropriate clinical support for physical therapists, in compliance with supervisory or employment agreements. Encourage compliance with relevant legal, ethical, and professional standards for clinical practice

For further information on risk management, please see the course Using Malpractice Claims Data to Identify Risks in PT Practice by Jennifer Flynn, CPHRM