April - June 1990
(Volume IV Number II)

Dear Physician:

As you are aware, you have the ultimate responsibility for the work done by the members of your office support staff. This includes any advice that they may give to patients, as well as any services they may perform or treatment they may render. We have had several cases where this has resulted in claims/suits against physicians. Therefore, we recommend that each practice define the scope of responsibility of each level of staff.

Of course, the guiding principle in establishing these scopes of responsibility should be the training and, where applicable, licensure/ registration of the staff member(s). Because of the danger of persons giving advice and treatment without the proper qualifications and to reduce our collective risk, medical practices must review and consider the training and licensure of staff members before assigning their duties. PRI has handled one case where an unlicensed and partially trained person administered injections for the treatment of severe arthritis; the patient suffered severe idiosyncratic damages and the case resulted in a very large payment. Even though the patient's outcome probably would have been the same if the injections were given by a physician, this issue weighed heavily against the defense, when presented to a lay jury. In this case, the question hinged on whether or not additional history would have been obtained by more properly trained staff.

The review of licensure and training should not be limited to a onetime procedure at hire, but copies of licenses and relevant certificates are to be obtained and kept on file. When these documents are renewed, copies should also be obtained.

The following list may be helpful in defining scope of responsibility:

QUESTION:

With the exception of those categories of staff who, by law, may write prescriptions, do other staff members prescribe medications and/or renew them?

Recommendation:

It must be clear to all staff members, as to who may give prescriptions to patients, or renew medications.

It is preferable that the physician make the chart entry regarding the renewal or cosign the staff member's note. At the very least, the note must state that the medication is being renewed "as per" the physician.

We have had cases where significant delays in treatment resulted, because a staff person offered advice and prescribed medications for reported symptoms (especially over the phone).

QUESTION:

Are there instances when non-clinical staff are required to perform functions such as giving injections, dispensing medications, removing sutures, obtaining history etc.?

Recommendation:

Persons who are not clinically trained may not perform clinical functions. We have experience with cases ranging from improperly administered injections to inadequate histories obtained, which formed the basis of suits against physicians. These cases have also included the administration of allergy injections.

QUESTION:

Are there specific criteria as to who may give medical advice to patients and under what circumstances?

Recommendation:

Because of cases where untrained and improperly guided personnel have given instructions to patients, we recommend that the responsibility of triaging patient calls regarding medical issues and responding to them, only be assigned to specific staff members (other than receptionists). Of course, these must be persons with the kind of training which will help them to make appropriate assessments.

QUESTION:

If you have a walk-in practice, are there specific guidelines as to who may triage patients?

Recommendation:

Just as with telephone advice, we recommend caution in assigning triage responsibilities. Often, patients who need emergent care present themselves at walk-in facilities and these situations may not be quickly recognized by a non-clinical person.

QUESTION:

Is non-clinical staff responsible for reviewing incoming laboratory and other reports, for the sake of determining abnormals versus normals?

Recommendation:

Many reports received by the physician's office may not be properly assessed by someone without appropriate clinical training. We have cases where abnormal reports were overlooked and filed away by untrained personnel and, therefore, did not come to the physician's notice until there was an irreversible outcome for the patient.

QUESTION:

If you employ nurse practitioners and/or PAs who see and treat patients apart from the physician, do you have criteria (written) as to which patients they may see?

Recommendation:

Develop written criteria so that there is some guidance for the nurse practitioner and PA as to your preference concerning the treatment of certain kinds of patients. For example, may they see only well-babies or may they also treat sick children?

QUESTION:

How are you reviewing the work of the nurse practitioner or physician assistant?

Recommendation:

Ensure that there is a system which allows for patients to be seen by the physician at specific intervals.
We know that these providers are trained to render certain types of care independently, however, our Company has several cases on file where there was long term treatment without physician involvement. In most of these cases, there is an allegation of failure to diagnose various tumors and cardiac illnesses, resulting in significant impairment or death. The lack of evidence that the physician was in charge of the care of these patients will make them very difficult to defend.

QUESTION:

Does the review include cosigning medical record entries?

Recommendation:

If at a particular visit the physician does not need to write a note, the note of the nurse practitioner or PA should at least be cosigned, to indicate that the physician is aware of the care and treatment being rendered.

Many cases in which physician negligence is alleged, result from factors listed here or similar ones. It is incumbent upon each practice to decide upon the scope of responsibility of each level of staff and to establish guidelines for them. This will be beneficial not only from the perspective of medical liability but will also serve the goal of providing quality care to patients.

Below is a list of our Loss-Prevention Techniques:

Telephone Matters | Patient Relations | Test Results and Follow-up Monitoring Patients | Patient Follow-up
Guidelines for Comprehensive Office Chart
Emergency Prepardness | Developing Telephone Protocols
Medical Office Personnel | Medication Matters
Issues in Physician Coverage
Discounting the Doctor/Patient Relationship