The following guidelines have been developed and endorsed by the American Academy of Family Physicians.

Approved by the AAFP Board of Directors in November 1993, these guidelines represent the “core” educational objectives for training family practice residents in the field of risk management and medical liability. Family physicians in practice may wish to review the guidelines in preparing for their board examinations. Other specialists may refer to the guidelines in developing continuing education courses for family physicians or in preparing articles for American Family Physician.

Risk management refers to strategies that reduce the possibility of a specific loss. The systematic gathering and utilization of data are essential to this concept. The risk management process comprises:

* Identification of risk or potential

risk (diagnosis)

* Calculation of the probability

of adverse effect from the risk

situation (assessment)

* Estimation of the impact of the

adverse effect (prognosis)

* Control of the risk (management)

Good risk management techniques improve the quality of patient care and reduce the probability of an adverse medical malpractice claim.

This core curriculum outlines the attitudes, knowledge and skills currently recommended for residents in the area of risk management.

Attitudes

The resident should develop attitudes based on:

A. An awareness of potential risk

and professional liability.

B. An appreciation of the importance

of good communication.

C. An appreciation of the importance

of good medical records.

D. A sensitivity to the roles of federal,

state, commercial and

other agencies involved in risk

management and medical

liability issues.

E. An awareness of the inherent

conflict between defensive

medicine and cost

effectiveness, between individual

good and social good.

Knowledge

A. Physician-patient relationship

1. Definition

2. Termination

a. Mutual consent of parties
b. Physician services no
longer needed
c. Withdrawal of physician
from case after
reasonable notice to
patient and completion of
current treatment

3. Abandonment

B. Informed consent

1. Components

a. Diagnosis
b. Nature and purpose of
proposed treatment
c. Possible complications
d. Available probability of
success
e. Alternatives
f. Documentation of
conversations
g. Written form completed

2. Special patient situations

a. Minors
b. Mental incompetence
c. Emergencies
d. Therapeutic privilege

C. Communication

1. Doctor/patient

a. Time spent with patients
b. Use of clear, understandable
language
c. Careful and attentive listening
d. Sensitivity to needs of
patients
e. Flexibility in responses
to the spectrum of
patients
f. Mechanism for
addressing patient
complaints

2. Staff communication with

patients

3. Doctor/legal system

a. Response to request for
records
b. Subpoenas
c. Depositions
d. Attorney selection
e. Malpractice panels
f. Court appearances

D. Legal definitions

1. Sources of the law

a. Supreme law
b. Statutory law
c. Decisional law
d. Quasi-judicial law

2. General legal liability

a. Contract
b. Torts, intentional
negligence

3. Duty to exercise care

4. Applicable standard of care

5. Breach of standard of care

6. Causal relationship between

breach of duty and injury

7. Statute of limitations

8. Statutory immunity

E. Documentation

1. Physician record

a. Accurate
b. Complete
(1) Patient
examination
(a) Baseline history
and physical
examination
(b) Updated lists of
known allergies,
prior illnesses,
immunization
status
(c) Specific notes on
symptoms, patient
noncompliance,
patient responses
(2) Patient disposition
(a) Differential diagnosis,
current
diagnosis, therapy,
plan of action
(b) Specific time of
return visit
(c) Referral to other
physicians
including reasons
and date of
appointment
(d) Follow-up system
(3) Telephone calls
(a) Substance of telephone
conversation,
both during
and after office
hours
(b) Conversations
with patient, family
members and
other physicians
(4) Reports of tests
(a) Physician
acknowledgment
of results
(b) Inclusion in chart
(c) Follow-up plan for
abnormal results
(5) Technical matters of
form
(a) Preprinted forms
with fill-in-the-blank
style
(b) Little empty paper
(white space)
(c) All entries signed
and dated
(d) Pages securely
bound
(e) Complete entry
at time of
examination
(f) Missed or canceled
appointments noted
(g) Problem list
c. Legibility and readability
d. Proper corrections and
modifications
e. Timely completion of
medical records
f. Confidentiality
(1) Legal breach of
confidentiality
(a) Physical or sexual
abuse of children
(b) Patient presents
clear danger to self
or others
(c) Patient to be
involuntarily committed
to mental
health facility
(d) Certain health
conditions, i.e.,
human immunodeficiency
virus
(e) Reportable
communicable
diseases, i.e.,
tuberculosis, sexually
transmitted
diseases