Thank you for joining us for today's educational program, Life After Residency, Starting a Practice and Insurance Considerations. Content in this presentation is intended solely to provide general information concerning the developments in the area of risk management. It is not intended as legal or medical advice, nor does it offer or solicit for offers with respect to any insurance product. Legal or medical advice should be obtained from qualified legal counsel or professionals to address specific facts and circumstances and to ensure compliance with applicable laws and standards. And listeners should consult their own insurance advisors for information pertinent to the purchase of any insurance product. This content may not be reproduced or redistributed in whole or in part without the prior written consent of Allied World. My name is Kara Staus and I will be your speaker today. I am an Assistant Vice President in the Risk Management Group for AWACS Services Company, a member company of Allied World. I provide risk management consulting services to Allied World's medical professional liability policyholders and insured psychiatrists, psychologists, psychiatric nurse practitioners, and physician assistants. I work directly with policyholders to develop individualized action plans to mitigate potential loss based on their unique exposures and risk management needs. Additionally, I assist these clients with ongoing medical educational programs as well as policy and procedure development. So the objectives for today's presentation are to describe the types of medical malpractice insurance, summarize the types of claim allegations most commonly filed against psychiatrists, understand key considerations needed to establish a new practice, and to apply risk management strategies to reduce the risk for a potential medical malpractice claim or board complaint. So the areas we'll take the time to review today are medical malpractice insurance, who provides coverage, the different types of coverage, what is typically covered, what may not be covered, insurance considerations. We'll take a look at several different business insurance coverages. We'll talk about starting a practice. We'll talk about medical malpractice claims. And then lastly, we'll review best practices and risk mitigation strategies. So why is medical malpractice insurance so important? Well, it's a type of insurance or professional liability insurance that covers healthcare professionals against claims of injury and medical negligence. So essentially, it's a protection of personal assets and professional assets. This type of insurance is required by law in most states. It's often a condition of employment or of a contract of employment. And it also mitigates the cost of defense and indemnification in the event of a claim. So who provides medical malpractice insurance? There's several different vehicles of insurance groups that provide coverage. So many of you are familiar with traditional insurance companies, which typically involve a direct-to-provider or utilizing a broker or agent. A lot of you may be familiar with having a broker or agent for your personal insurance needs. So traditional insurance is basically when a company transfers risk to a third-party company that charges a premium and often requires a deductible. Captive Programs, a captive insurance company, is a wholly-owned subsidiary, which is typically formed by an organization. And it's used to provide risk mitigation services for the parent company and its related entities. So it's often used as a financial strategy and savings for organization, where they're essentially paying premiums to themselves. Risk Retention Groups, or RRG, is a state-chartered insurance company that insures commercial businesses and government entities against liabilities and risks. And then lastly, self-insurance programs. So self-insurance really involves setting aside money to pay for possible losses instead of purchasing insurance and expecting an insurance company to reimburse you. So with self-insurance, you're going to pay a cost for the medical procedure or damage to property or theft or anything like that out-of-pocket rather than filing a claim under your policy like you would traditionally with a traditional insurance program. So here we're going to take a look at some of the definitions. So the types of malpractice coverage that we talked about, occurrence-based. So what is occurrence-based coverage? This is a claim which is made during the policy period. So regardless of when the claim was made, even after your policy was canceled, if the event was during the policy period. So as noted, it's driven by the date the event occurred. These types of policies are less common. However, some insurance companies do offer occurrence-based policies and they are generally more expensive than claims made policies. So claims made policies, claims made and reported policies, they're going to be driven by the date the event is reported. So for this type of policy, the claim must occur and be reported while your policy is in effect with the insurance company. So claims made policies are one of the most common types of medical malpractice coverage. If you want coverage for a claim that is made after your policy is no longer in effect, you will need to potentially purchase tail coverage. So tail coverage extends your policy for a certain period of time. For example, it may extend coverage for five years after your policy ends. While it can be expensive to purchase tail coverage, it also can help cover you in the event any claims arise after the fact. And it can be a good option for you if you're switching policies such as starting a new position or retiring or anything like that. So again, we're going to look at the date driven by the event. We have tail coverage. There could be prior axe coverage, also known as nose coverage, retroactive date, and potential gaps in coverage. So admitted versus surplus line coverage. What is the difference? Admitted carriers are licensed by states in which they write business, and they must conform to rate and form regulations within the state they are licensed to provide coverage in. Whereas excess and surplus line carriers, they're not licensed by the state, but they are allowed to do business in the state, traditionally through a wholesale broker or managing general agent. So next we're going to talk about examples of what is typically covered by a medical malpractice policy. So negligence. So negligence related to a professional act. An example of this could be failure to diagnose or prescribe proper psychiatric medication. Alleged breaches of patient confidentiality under HIPAA. So sharing of information without the proper consent or release of information from the patient. Vicarious liability. So office staff or other physicians, mental health providers, that you may be responsible for the acts of your staff. Whether you are held legally responsible is another issue. So psychiatrists often may find themselves in a supervisory role of another clinician and provide professional direction of the care of the patients to these clinicians. So it's important to know that in the legal doctrine, vicarious liability comes into play. So in other words, the doctor may be responsible for the acts of another provider. And so it's important to understand that role. In addition, you should know who's covered and not covered under a medical malpractice policy. So some considerations would be, is it the entire group? Are residents, students, and interns covered? Independent contractors or other healthcare professionals? Medical director. So again, these are the types of considerations as you are looking at coverage, looking at practice options to consider when you are reviewing your coverage. So what may not be covered by medical malpractice? So it goes without saying, criminal, fraudulent, or malicious acts may not be covered. More than likely, they won't be covered. Intentional acts, something intentional that was done may not be covered. Discrimination or harassment. If you are operating outside the scope of rendering your professional services as a licensed psychiatrist, it may not be covered. Any medical licensure issues, such as your license has lapsed, or you're practicing out of state where you're not licensed to practice. Disciplinary actions, or again, practicing outside your scope or specialty. Those are some of the considerations as you begin to practice you need to be mindful of. Matters not reported timely. I will make particular points to highlight that. It's important that in the event you are made aware of a situation involving a patient that could give rise to a claim, that you provide proper notice to your medical malpractice insurer. Again, you want to make sure that you have reported something so that they have the ability to investigate timely. Alleged breaches of confidentiality. While there may be some coverage afforded under a traditional medical malpractice policy, it may be limited. We will talk about on one of the slides regarding other business coverages, that this is something that most likely would be covered under a cyber liability policy. Then lastly, additional insureds. In the event you have vendors or subcontractors, they may not more than likely be covered under your medical malpractice policy. Again, unless that's been reported to your medical malpractice insurer and they are aware of that and have added them to your policy. Again, be particular aware of individuals that you are operating and doing business with to ensure that they have the appropriate coverage when working for you. So as you consider malpractice companies and coverage, it's important to ask these questions and have the insurance professional you're working with explain in detail so you understand exactly what your policy covers and what it doesn't cover. So does your policy cover defense expenses within the limit of liability? Or is it in addition to? This is a very important question as defense expenses can be costly and reduce your limit of liability when they are within the limits. So what are your policy limits? So traditional policy limits may range and vary. They may be $1 million, $3 million, or $2 million, $5 million. You really would need to work with an insurance professional to determine the amount of coverage which would be appropriate for your practice setting and to protect your business and your assets. Does your policy include regulatory matter coverage? Again, in the event you receive a complaint, let's say from the OCR, the Office of Inspector General, would your policy provide coverage for that matter? These are very important questions to ask to understand exactly what your policy covers and what it does not cover. And lastly, we talked about vicarious liability. So when you are supervising other staff members, whether you are supervising them in practice, working within your clinic setting, or you're simply providing supervision for a mid-level practitioner who needs additional supervision hours as they are working towards their additional licenses, it's important for you to understand what your policy covers in the event of the claim and where it would fall under. So understanding insurance is a daunting task. And in addition to medical malpractice coverage, there are several other types of insurance that you will need to consider in the event you choose to start your own practice. So professional liability insurance is used to protect businesses against claims for negligence. General liability insurance policies are typically covering you and your company for claims involving bodily injuries and property damages from products and services. So let's say you had an individual who walked on your property into your office and slipped and fell on ice in the winter. They may have a claim under your general liability policy. Cyber liability and data security, this is probably one of the best coverages and most necessary coverages to have in this age of technology. With so many hackers, it's important to protect your business and make sure that you have cyber liability and data security coverage. Directors and officers insurance protects the personal assets of any corporate directors and officers in the event they are personally sued by employees, vendors, competitors, contractors, or any other parties for actual or alleged wrongful acts related to managing the company. Workers' compensation. So this is a statutory and state-specific insurance and requirement as an employer when you're employing staff to work with you. And it covers the employees for medical treatment, wage replacement, and related benefits in the event of a work-related injury. Malpractice liability, also known as EPL. This coverage would be coverage for defense costs and damages related to various employment-related claims. So for example, if an employee alleged wrongful termination or discrimination, workplace harassment, retaliation, if you remember a couple of slides ago, it was noted that these types of matters wouldn't be covered under your malpractice policy because again, there is a specific policy that would cover these types of acts in the event they did occur. Commercial property. Commercial property insurance protects your company's physical assets in the event of let's say a fire, you know, a pipe bursting, storms, vandalism, or theft. Business interruption insurance is insurance coverage that replaces business income in the event of loss or from a disaster. So an example of business interruption, you know, probably most relatable is with the hurricanes that we've seen and these natural disasters where companies may not be able to operate, that there could be a need to utilize business interruption insurance. And then lastly, crime and employee theft coverage typically is an endorsement on a policy for coverage to the employer from financial loss due to any fraudulent activities of an employee or a group of employees. So there are several considerations and types of practices as you begin, you know, to venture out. So whether you're a new physician who just completed residency or a fellowship or an experienced provider who's considering an employment change, there are a number of practice arrangement options to consider. So there's three areas, you know, specifically to consider. So are you considering forming your own practice and will this be a solo practice or partnership? Those are some considerations. Are you considering joining an existing group practice as an employee, partner, or shareholder? Or will you be joining a group practice as an independent contractor? And as if hired as an independent contractor, it's really important to have an attorney review your contract so that you're aware of any non-compete clauses. And again, with all considerations in practice, whether it be opening a solo practice or partnering or joining group practices, having advice from legal counsel is essential so that your interests are protected. So we talked a lot about insurance so far, and there's other things to consider when starting a practice. And so our recommendations would be to establish office policies and procedures. So it's important to have really a roadmap of what your expectations are within your office. You're going to need to file your business with the state or federal organizations and get the appropriate licensing and numbers in order to operate within the state and federal guidelines. You may need to engage in vendor relationships. So if you are leasing a building, you may need to find a housekeeping service to take care of cleaning your business. There may be snow removal if you're in one of our states where weather is an issue. Software and technology. It's important to look at software and technology vendors. Will they be providing your electronic health record? Will they be doing your billing? Considering those types of vendor relationships. Obviously we went in great detail over all the types of insurance coverages you may need. Professional organization memberships. Do you need to join? Are you a member? Is there any benefit cost savings to being a member? Are there discounts associated with some of these insurances by being a member of professional organizations? Can they provide you with additional resources and guidance? Safety and security. Obviously that's huge. It's one of the big issues we see is the safety and security of not only you, but your patients and your employees that may be coming and going from your business. Human resources. So the human element of working and having staff within your organization. Your employment practices. It's important for you to consider whether or not you have to have a office manager who's well-versed in human resources. And then obviously are you going to be leasing, renting or buying a space for your practice? And what are the considerations for that? Location, parking, access, all of that. So in addition to your practice policies, there are also several policies for patients that are important to note. So establishing policies and procedures are important for your patients because it really sets the standard and the expectations required to be a patient in your practice. I often refer to them as, you know, contracts between you and your patient. And so what do you expect of your patient? And really what should the patient expect of you by being a patient within your practice? So privacy notice. Your notice of privacy practices needs to be posted and needs to be shared with your patients. Having your HIPAA authorization. Those policies are important in the age of privacy and technology. Having patients understand that your practice is in compliance with HIPAA is essential. Obviously treatment and medication consents. Do you have a policy associated with your treatment? You know, what are the expectations for treatment? If you are prescribing medication, do you have policies associated with that or expectations for patients to comply with? Patient termination from practice. It's important to follow your own standards and for patients to understand, you know, what your policy may be in the event you do need to find yourself discharging a patient from the practice. What is your policy for the use of email, texting and social media? Do you have one? It is recommended that you consider putting some language into your office paperwork to know how email should be used, how texting should be used, if you allow it, don't allow it. And then obviously social media, so that again, there are parameters established for all patients that are in your practice. And then practice provider and the patient. Again, as we're talking about all these elements, these policies associated with, you know, the start of care treatment plans. Duty to warn. Understanding the requirements in your state for duty to warn under certain circumstances, so mandatory reporting, making sure patients understand what your reporting obligations are, and also duty to warn. So make sure you're aware of your state-specific requirements in these areas. What is your practice policy for appointment scheduling or cancellations? Do you require payment of appointments if they are canceled within a certain timeframe? You know, make sure that you've established that upfront. So that there is no issues down the road. Again, if there are late appointments or frequently missed appointments or rescheduling, you may need to consider, you know, incorporating that policy so that patients don't take advantage of that. And then referrals. Do you have a need to refer patients out of the practice? Again, making sure that the patients understand what your process is for referrals. So we're talking an awful lot about policies for you and your business, for your patients, and now we're gonna talk about policies for your staff and your practice. So again, it's so important to establish these policies. If you plan to hire staff, whether it's other mental health professionals or individuals who may be managing billing or reception, it is important for staff to be aware of policies and procedures. So do you have your documentation? So your medical record documentation, your telephone and billing documentation, and record-keeping requirements? You know, record-keeping requirements are going to be state-specific. So again, make sure you incorporate that into your office practices policy. So HIPAA compliance, which includes a workforce confidentiality agreement, it is best practice to incorporate that workforce confidentiality agreement because you want to be sure that any staff person working in your office is aware of HIPAA and the need to maintain privacy for all individuals that come into the practice. Having staff sign off on that is important so that they understand, especially in healthcare, the sensitivity of the work that they are doing. So what is the acceptable and unacceptable use of social media, email and texting? You know, do you want staff using the office email for personal use? Do you want them posting on social media? Again, these are some considerations as you look to establish a practice. Record retention and plan. As I had mentioned, your medical records are going to have state-specific regulations, so make sure that you are familiar with how long you need to keep a patient record. In addition, under HIPAA, you do need to keep a log when you destroy records. So it's a record destruction log, so you want to keep a log for when you destroyed that record, the date that it was destroyed. Do you have a policy and procedure for your practice business records? So again, what are you keeping? How long are you keeping it? You want to make sure that you have a plan outlined. Emergency management plan. An emergency management plan is essential so that you and your staff understand what happens in the event of an emergency. And the emergency could be a weather emergency. You know, we had emergency use that we had to put into place, oh, it's now three years ago with the pandemic. And so having that emergency contingency plan in place there's operations that continue is important so that staff know and patients know what that plan is, whether it's a recording on your telephone, whether it's a notification on your email of what's to happen in the event of an emergency plan. If you have a telephone tree, again, these are some recommendations and considerations. Workplace violence and prevention plan. Again, workplace violence, it's important that we keep everybody safe in the workplace and so make sure your staff are prepared to handle any situation within the office and that there is a prevention plan in place. So make sure that there's well-lit parking lots, make sure that staff are not alone when treating patients in the office, make sure that if they need to have, you know, the ability to call somebody, those are important recommendations for your office staff. Handling of grievances and complaints. This is important too. If somebody does bring up a complaint to your office staff, what do they do with it? Who do they tell? Do they tell you, the physician in charge, or is there a practice manager that handles the complaints? So again, having a policy and procedure makes it a lot less, you know, likely for an error to happen or a misstep to happen. And you can easily guide and follow that policy. And then lastly, job descriptions. What are the expectations of the staff and the jobs that they've been hired to do? So as you consider starting a practice, there are several consultants that you should be engaging with to answer any questions that can assist you in developing your business or the considerations of what type of business you wanna engage with. So obviously, if you're looking to be employed by a healthcare system or clinic, you wanna consult with them and ask questions. You may need to find an insurance broker or agent to talk about your medical malpractice coverage or other coverages if you are choosing to go into a solo or private practice. A group practice attorney. It's always recommended to have a attorney that is well-versed in obviously practice and healthcare so that they can give you advice and counsel for all those business-related issues that do come up. A financial advisor. A financial advisor may assist you in identifying which coverages are needed to protect your financial assets and what type of business would be best suited for you. Risk management professionals can provide you guidance as well. Your licensing boards will provide you with appropriate guidance as well of what is required. And then don't forget about your professional associations. If you are a member of your professional association, there are resources available to you to help guide you and answer questions in the event you have them. So we're gonna transition now and talk about common claims and allegations in psychiatry. And so it's important to note that licensing board complaints are more likely to happen than malpractice suits for psychiatrists. However, they do happen. And so the list of common claims that we have seen are the following. So we're gonna review them. So improper assessment of suicidal or violent patients. And so did you take reasonable measures to prevent risk or violence? Were appropriate steps taken? So it's important to complete that assessment and document the medical record thoroughly of what you did. Did you assess them? Did you make recommendations? Did you recommend them for a higher level of care? Was there increased monitoring? Was there a safety plan put in place? What exactly were the measures to be put in place? Failure to diagnose. Failure to recognize or diagnose in psychiatry sometimes can be difficult. However, we're gonna be looking at the methods used in the standard of care when looking at failure to diagnose. So improper treatment may also be looked at as improper monitoring or failure to monitor the patient. Informed consent. Informed consent is an issue that often comes up and it's really the documentation of the informed consent. And understanding that informed consent is not a form. It's a conversation with the patient reviewing the risks and benefits of the treatment. So make sure that that informed consent document is signed because that signed piece of paper represents that the patient has acknowledged that you have gone over the risks and benefits of the treatment you're providing. Vicarious liability. Vicarious liability, again, we've talked about is the office staff or other physicians or mental health providers. You become responsible for the acts of your staff. So whether you're held legally responsible in the court of law, well, that would be up to the courts to decide. So you may find yourself as a psychiatrist in a supervisory role. And so it's important for you to understand your role as a supervisor. So understanding what is state-specific level of clinician you may be supervising and also the documentation that you may be signing off on. Again, being aware of the acts of the clinicians that you are overseeing, that is where vicarious liability comes into play. So it's not a defense to say you were not aware of the circumstances surrounding the claim. Prescribing. Prescribing is important. So it's important to document side effects such as toxicity, document side effects, and document any physical effects of the medication. Take appropriate steps to monitor and manage these effects. Are there any black box warnings or off-label use? Again, make sure that the patient is aware of the effects of the medication. Proper use. Again, make sure that the patient understands the medication, the use, and proper prescribing and dosing of the medication. If there's lab work that is required as a result of the medication, make sure that the patient is followed for that lab work and those results are reviewed. Abandonment. Abandonment claims often happen related to communication. And communication and termination, we say termination is not a one-time event unless there's a risk of a threat of harm to you, the provider. So have conversations with the patient before termination, whether they need to be transitioned to a different level of care, whether they've been non-adherent to the plan of care and it's time for them to transition to another or more suitable provider. Again, make sure that you're documenting and addressing the potential for discharge so that the allegation of abandonment cannot be made. So it's important for you to document the referrals made, any emergency coverage, and any medication. Know that HIPAA, obviously privacy breaches and confidentiality sharing information with family members or others that you may not have had consent to. Boundaries or ethics in the event a patient files a boundary or ethical complaint. They may have felt that you have crossed a boundary or done something unethical. Or a patient, you know, may not be adhering to your policies and procedures, and you may have to proceed with discharge determination as a result of boundaries. Again, make sure you're documenting that. And then patient rights and civil commitment. Did you have to send a patient to the emergency room as a result of their mental illness? Because they did need advanced monitoring. And were they upset? Were they angry with you? With your decision? So again, make sure that you are documenting these matters thoroughly. For all of these allegations, it's important to know that there are elements that need to be brought forward before a claim for medical malpractice can be met. And so the injured or aggrieved party must prove each of these elements in a medical malpractice lawsuit. So first of all, the physician must have owed a duty to the patient. And the physician who owed the duty to the patient must have breached the standard of care. So understanding what the standard of care is, and so the knowledge and skill that that physician in the same specialty would have used in an equal situation. The patient must have sustained an emotional or physical injury, whether it's a new injury or an exacerbation of a preexisting injury. And that breach of duty by the physician is causally linked to the patient's alleged injury, so the damages. So again, it's important for you to understand the standard of care varies by state to state and is often driven by where the patient is located. And it may vary by the setting, so urban versus rural. So keep in mind, as I mentioned, that psychiatrists generally have one of the lower rates of lawsuits. And child and adolescent psychiatrists have an even lower rate. So what do you need to do in the event an incident, adverse event occurs? So it's important for you to immediately notify your insurance carrier, broker, or employer. And we highlight those because each situation, depending upon your employment status, you may be reporting to your employer, you may have an insurance broker you're reporting it to, or you may have an insurance carrier. So you may not know that the incident occurred, but you may get a letter of representation or a demand for compensation. And if that does happen, that's notification. Don't attempt to contact the person who's sending the letter. Contact your insurance provider and show them a copy of that letter before making any other phone calls. You may be given a summons and complaints that you're served with an actual lawsuit. You may receive a letter from the board complaining about you. Again, make sure you are communicating with your medical malpractice insurer so that they can appropriately advise you on how to handle these certain circumstances. There may be an adverse event that has injury or harm that you're concerned about. Make sure you do notify your insurance carrier of that notice of a potential event. And then if you receive a subpoena or court order, depositions, make sure you are, again, notifying your insurance carrier. You want to make sure that you are given proper guidance before responding. And again, these are all timely events, so it's important for you to notify them immediately. So what you should do is in the event of an adverse event or incident, document the incident factually. You know, state the facts. If you have questions, seek advice from a risk management professional or a group practice attorney for more guidance. And then do be cautious and limit your conversations with others about the incident. Again, you don't want other people to be involved unnecessarily, especially in the event of litigation where other, you know, parties may be called to be deposed if it is found out that you did discuss an event with them. And of course, any time an incident recurs or you receive a complaint or a demand letter, it, of course, comes with stress. Make sure you're taking care of yourself and addressing your own personal stress. So do's and don'ts of the incident. So consider how a jury might look at your documentation. Don't change your documentation. Look at it. Be familiar with what has transpired that would have caused the complaint. You know, document that that incident took place. Document in the record what happened. If you have to fill out a separate incident report as required by your employer, don't mention the incident report in the medical record. The medical record alone, you should just document the facts of the event. It's important that you understand any apology statutes that your state may have and how that applies in the situation regarding any adverse event or incident that happens. And it's always important to make time to participate in your own defense. You know, defense of any claim or allegation of malpractice can be stressful, but you play a very important role, and it is important to take the time to understand what that role is and what you need to do in order to have a favorable outcome for you. Understand the strengths and weaknesses of the claim, you know, and that is going to be from the professionals that you are working with to defend your claim. They're going to be very honest with you after they review the facts of your case, and they're going to share what is a strength, what is a weakness. And always be open minded and willing to collaborate with defense counsel. Again, remember the defense counsel is on your side, and they're there to help you. So you want to make sure that you're sharing information, you're collaborating with them, and you're open to conversation. And obviously, defense counsel is going to be supportive and preparing you for any potential deposition or trial in the event a claim heads down that path. So it's important for you to not communicate directly with a patient's attorney. So oftentimes, patient's attorneys, they may even contact you, you know, regarding other matters that are involving a claim. And it's important for you to not to communicate with them directly, especially if there's a complaint related to care. You want to make sure that you are not communicating with them. You, number one, don't have a release of information to speak with them. And number two, you have, you know, a duty to the patient if there's still a patient in your practice. But if a patient's attorney is reaching out to you, take pause, pick up the phone and contact your own attorney before proceeding. Do not offer to settle any claim on your own. It's important for you to understand the risks of that and any implications. So again, if someone reaches out to you to attempt to settle, again, talk to your malpractice insurer for guidance on claim settlement. They are the professionals who can guide you and get you the best possible outcome related to claims. Don't wait to report the event. We talked about reporting it immediately. Once you are made aware of a potential incident, pick up the phone, contact your malpractice insurer and report that event. You know, again, the sooner you report the event, the sooner the claims professional can start to investigate and work with you in order to mitigate any potential losses and damages related to the claim. Do not abandon and have clear patient communication. So again, it can be very difficult in the event you receive a complaint related to care regarding a patient. It's important for you to understand, you know, what your duty is at that time. And you may have to discharge or terminate the patient, but you need to communicate clearly and handle the process accordingly within your state guidelines. So again, avoidance is not going to be recommended, but do handle it appropriately. And if you need guidance, contact an attorney or a risk management professional for guidance. And it goes without saying about altering or changing medical records in the event an incident recurs. Do not change or alter anything that's already taken place in the medical record. Know that that medical record is really the details and the facts have already been, you know, established. If it's an electronic medical record, every keystroke is recorded in a computer system. So don't touch the record. It's not necessary for you to make changes. It is not recommended. And it can ultimately hurt you. It can make a defensible case indefensible in the event there is a change made after a complaint or incident occurs. So with paper records, obviously, you don't want to be destroying anything. And then electronic medical records, again, as I indicated, keystrokes are recorded through the metadata in computer systems. So best practices and risk management strategies are always going to adhere to the standard of care, which you're all prepared to do in your profession. So using reasonable precautions and performing appropriate assessments when you're treating suicidal or violent patients is critical. You know, have a thorough assessment documented in the record. Give, you know, detailed descriptions of how that patient is presenting and any actions and follow-up that you have taken in regards to treating that patient. Monitor for medication side effects. If the patient is reporting side effects or even if it's a new medication, monitor and follow-up and document those conversations with the patient. And your federal and state regulations as it pertains to your scope of practice. Any other state regulations that may be in play, such as discharge or termination, such as medical record retention, such as general practice. One thing within, you know, psychiatry is licensure in the age of telemedicine, knowing that your license is in the state where the patient is. So again, understanding these rules is important to risk mitigation. Use sound documentation principles. Again, be thorough in your documentation. Be succinct, accurate, and to the point. Document contemporaneously so that your documentation is reflective of the care and treatment and shows a complete story of the patient's care with you. Include in the medical records, if photos are appropriate, text or emails. Any voicemail messages need to be transcribed into the medical record. It's important to avoid documenting your opinions, any excuses, criticism or blame, or even staff conflicts that doesn't belong in a patient's medical record. Remember, that medical record can be viewed by the patient at any time. And in the case of a defense of a malpractice claim, it's going to be viewed by many people. It's always important and paramount to protect patient privacy and confidentiality and understanding the expectations under HIPAA. Use good cyber hygiene. In the age of technology and smart devices, it's important to be mindful at all times of the risks associated with technology. Documentation of the informed consent and informed refusal. Again, we talked about documentation, that electronic communication, make sure you're documenting. Telehealth. Documenting telehealth encounters. Where is the patient located at the time of the encounter? Make sure that they're consenting to the telehealth session. Creating office policies and procedures is an important component to risk mitigation. You should be looking at them annually and know that the notice of privacy practices is a requirement for patients to know what the practices, the privacy practices of your practice are. Make sure that patient's information is updated and employee policies and procedures are updated. Be aware and mindful of the use of social media. You know, social media can be used as a great marketing tool to market your business, but be mindful of the role of social media and avoid using it to where there is an exchange of dialogue that could construe a, you know, doctor-patient relationship and the risks associated with that. So again, be considerate of social media and the utilization of that. Always maintain professional boundaries and psychotherapy notes. Psychotherapy notes are given in added protection and it's important for you to utilize that added protection. If those psychotherapy notes are kept separate from the rest of the medical record, whether it's a separate tab in an electronic record or if you're on paper, it's in a separate file, those records are your personal notes and they are not to be released in the event of a request for medical records. Psychotherapy notes have protections and they are not a part of the designated record set within the medical record. So again, be aware of the protections within documentation and make sure that you are documenting and keeping those notes. If you do keep psychotherapy notes, keep them separate so that you don't have to release them and you are maintaining compliance with the federal code for documentation of psychotherapy notes. And then in closing, you know, remember if it wasn't documented, it wasn't done. You know, the old adage, you know, making sure that you're documenting that thorough, complete story of the patient. Understand, understand what's needed to begin practice. We covered a lot of material today. We talked about a lot of different insurances, a lot of different policies and procedures. So again, understand what is needed for you. Investigate, really take the time and investigate what you might need and what would work best for you and your practice. And consult with people, ask questions, you know, ask a lot of questions. Insurance is dynamic. There's a lot of options. So consult with the professionals who understand insurance and can give you the best possible guidance. And then we want you to think like a juror. Think like somebody reading documentation that has no medical background. So what are they looking for? They might be looking for loopholes or gaps. So again, as you're starting out in practice and thinking about claims or documentation, think about how you can reduce and mitigate your risk. So thank you for joining us for this presentation. If you have any questions regarding today's presentation or any insurance needs, please contact the APA Endorsed Professional Liability Program, American Professional Agency, Inc. at 1-800-421-6694. You can email at psychiatry at americanprofessional.com or visit their website at www.americanprofessional.com. Thank you.

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