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Home , Risk control

October 9, 2017 8:05 AM

Risk Control Self-assessment for Nurse Practitioners Thisresourceisdesignatedtohelpnursepractitionersevaluateriskexposuresassociatedwiththeirpractice�Foradditionalrisk controltoolsandinformationgearedtotheneedsofNPs,visitwww.cna.comandwww.nso.com�

Scope of Practice Yes No Comments/Action Plan I read my state nurse practice act at least once per yeartoensurethat Iunderstandandprovidecarewithinthelegalscopeofpracticeinmystate� I know and comply with the requirements of my state regarding physician collaborative or supervisory agreements,andIreviewandrenewmyagreements atleastannually� I collaborate with or obtain supervision from a physicianasdefinedbymy statelawsand/orregulationsandasrequiredbytheneedsofmypatients� I seek alternative physician consultationifIamnotprovidedwithappropriate supportfrommycollaborating/supervising/employingphysician(s),andmodify myagreementsaccordingly� I decline to perform requested actions if they are outside of my legal scope of practiceasdefinedbymystatenursepracticeact�

Nurse Practitioner-Patient Relationship Yes No Comments/Action Plan Are problems clearly conveyed to patients,includingthespecificrisks associatedwithnotcarryingoutinstructions?Forexample,“Your wound must be cleaned three times a day in the first week after surgery, in order to avoid hard-to-treat infections and permanent scarring. What questions do you have about dressing changes?” Are patients told that they must take some responsibility for the outcome of their care or treatment?Forexample,“We both want you to benefit from treatment, but the results depend upon the effort you make.” Do practitioners relate personally to patients, in order to build a stronger therapeutic partnership?Forexample,“Tell me, what can I do differently to better help you meet your personal health goals?” Are staff trained to communicate with difficult patients,usingworkshopsand role-playingscenarios? Are patients encouraged to identify goals and preferences on their own? Forexample,“Let’s talk about what you wish to accomplish and what you think is a suitable approach.” Do patient encounters begin with a discussion of the patient’s personal concerns, rather than a recap of laboratory or diagnostic workups?Forexample, “First, tell me what concerns you most, and then we’ll discuss test results.” Does each encounter end with the patient verbalizing at least one self- management goal in a clear and specific manner? Forexample,“I will monitor blood glucose levels before meals and at bedtime between now and my next appointment.”

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA AND NSO RISK CONTROLCNA NURSE SELF-ASSESSMENT PRACTITIONER CHECKLIST Claim Report FOR: 4th NURSE Edition PRACTITIONERS PART 1 64 1 October 9, 2017 8:05 AM

Documenting Patient Healthcare Information Yes No Comments/Action Plan Are all written entries in the healthcare information record legibleandsigned inink,anddotheyincludethedateandtimeofentry? Are healthcare information records free of subjective commentsaboutthe patientorotherhealthcareproviders? Is there a formal procedure for compiling patient healthcare information, aswellasforhandlingandaccessingpatienthealthcareinformationrecords? Is the filing system logical,makingiteasytolocateandhardtomisplacepatient healthcareinformationrecords? Does the record-keeping system deter staff from making unauthorized entriesinpatienthealthcareinformationrecords? Are computerized records backed up daily,andisbackupinformationstored off-site? Is a system in place for training new employees in office record-keeping methods,includingelectronichealthcarerecordsandcomputerizedphysician orderentry(CPOE)systems,asappropriate? Does the office have a system in place for record review/quality assurance, andarerecordauditsperformedonaregularbasis? Are healthcare information record audit findings discussed with staff, includingsuchareasas… --Patientledger? --Referralforms? --Consultationletters? --Patientcorrespondence? --Telephonecommunications? Is a comprehensive medical history takenoneverynewpatient? Are the patient’s current prescription medications and over-the-counter remedies documented and checked for potential interactions at every encounter(e�g�,bycallingthepatient’spharmacist,ifnecessary)beforeadditional drugsareprescribed? Is critical medical information prominently displayed inside the healthcare

information record,includingdrugallergies,chronicconditions,majorprocedures October 9, 2017 8:05 AM undergone,medicationregimens,etc�? Is the patient’s medical history reviewed and updated at every consultation orDocumentingtreatmentvisit? Patient Healthcare Information (continued) Yes No Comments/Action Plan Is every visit documented in the patient healthcare information recordand This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means ofar initiatingethe internalfollowing discussionactions and self-examination.andinformation Your clinical proceduresnoted: and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual-- Date situationin compassingfull(month/day/year) a review relevant laws andof regulations.examination CNA assumesor notr eatment?responsibility for the consequences of the use or nonuse of this information. -- Reviewofmedicalandmedicationhistory? -- Chiefpatientcomplaint? -- Clinicalfindingsandobservations,bothnormalandabnormal? -- Diagnosis? -- Receiptofinformedconsent? -- Referral,ifnecessary? -- Prescriptionsandover-the-countermedications? -- Postoperativeandfollow-upinstructions? -- Plansfornextvisit? Does the patient healthcare information record note the rationale for not following a previously documented planCNA of care ANDand NSOother RISKimportant CNACONTROL NURSEmedical SELF-ASSESSMENT PRACTITIONER CHECKLISTClaim Report FOR: 4th NURSE Edition PRACTITIONERS PART 1 652 decisions? Are canceled appointments and no-shows documentedinthepatienthealth- careinformationrecord,aswellasattemptstocontactthepatientandreschedule appointments? Is evidence of patient satisfaction or dissatisfaction documented,including specificcomplaintsandconcerns,aswellasfavorablecomments? Are instances of noncompliance documented,aswellasdiscussionswith patientsregardingconsequentrisks? Are treatment complications documented,aswellasunusualoccurrencesand correctiveactionstaken? Are all pertinent discussions documented,whetherinpersonorbytelephone? Are all referrals to specialists and consultants documentedinthepatient healthcareinformationrecord? Is the patient given written, customized postoperative instructions,andare theseinstructionsdocumented? Are telephone consultations documentedinthepatienthealthcareinformation record,includingboththeconsultant’snameandtheinformationreceived? Are specialists asked to submit a written report following consultations,using astandardreferralformthatisretainedinthepatienthealthcareinformationrecord? Does the referral form include space for the following basic information, ataminimum: -- Thepatient’sname? -- Thediagnosticsofferedtothespecialistandthedatetheywerecollected? -- Theprimarypractitioner’sdiagnosis? -- Thetreatmentcompletedtodate? -- Thetestorprocedurethespecialistisexpectedtocomplete? -- Theinformationneededfromthespecialist?

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA NURSE PRACTITIONER Claim Report: 4th Edition PART 1 66 October 9, 2017 8:05 AM

Documenting Patient Healthcare Information (continued) Yes No Comments/Action Plan Is every visit documented in the patient healthcare information recordand arethefollowingactionsandinformationnoted: --Dateinfull(month/day/year)ofexaminationortreatment? --Reviewofmedicalandmedicationhistory? --Chiefpatientcomplaint? --Clinicalfindingsandobservations,bothnormalandabnormal? --Diagnosis? --Receiptofinformedconsent? --Referral,ifnecessary? October 9, 2017 8:05 AM --Prescriptionsandover-the-countermedications? --Postoperativeandfollow-upinstructions? Documenting--Plansfornext Patientvisit? Healthcare Information (continued) Yes No Comments/Action Plan IsDoes every the visit patient documented healthcare in informationthe patient healthcarerecord note information the rationale record for notand  arefollowingthefollowing a previouslyactions documentedandinformation plannoted: of careandotherimportantmedical decisions?--Dateinfull(month/day/year)ofexaminationortreatment? Are-- canceledReviewof appointmentsmedicalandmedication and no-showshistory? documentedinthepatienthealth- care--Chiefinformationpatientrecord,complaint?aswellasattemptstocontactthepatientandreschedule appointments? --Clinicalfindingsandobservations,bothnormalandabnormal? Is evidence of patient satisfaction or dissatisfaction documented,including --Diagnosis? specificcomplaintsandconcerns,aswellasfavorablecomments? --Receiptofinformedconsent? Are instances of noncompliance documented,aswellasdiscussionswith Referral,ifnecessary? patients-- regardingconsequentrisks? Prescriptionsandover-the-countermedications? Are-- treatment complications documented,aswellasunusualoccurrencesand Postoperativeandfollow-upinstructions? corrective-- actionstaken? Plansfornextvisit? Are-- all pertinent discussions documented,whetherinpersonorbytelephone? Does the patient healthcare information record note the rationale for not Are all referrals to specialists and consultants documentedinthepatient following a previously documented plan of careandotherimportantmedical healthcareinformationrecord? decisions? Is the patient given written, customized postoperative instructions,andare Are canceled appointments and no-shows documentedinthepatienthealth- theseinstructionsdocumented? careinformationrecord,aswellasattemptstocontactthepatientandreschedule Are telephone consultations documentedinthepatienthealthcareinformation appointments? record,includingboththeconsultant’snameandtheinformationreceived? Is evidence of patient satisfaction or dissatisfaction documented,including Are specialists asked to submit a written report following consultations,using specificcomplaintsandconcerns,aswellasfavorablecomments? astandardreferralformthatisretainedinthepatienthealthcareinformationrecord? Are instances of noncompliance documented,aswellasdiscussionswith Does the referral form include space for the following basic information, patientsregardingconsequentrisks? ataminimum: Are treatment complications documented,aswellasunusualoccurrencesand --Thepatient’sname? correctiveactionstaken? --Thediagnosticsofferedtothespecialistandthedatetheywerecollected? Are all pertinent discussions documented,whetherinpersonorbytelephone? --Theprimarypractitioner’sdiagnosis? Are all referrals to specialists and consultants documentedinthepatient October 9, 2017 8:05 AM Thetreatmentcompletedtodate? healthcare-- informationrecord? Thetestorprocedurethespecialistisexpectedtocomplete? Is -the- patient given written, customized postoperative instructions,andare Documenting Patient Healthcare Information (continued) Yes No Comments/Action Plan these--Theinstructionsinformationdocumented?neededfromthespecialist? Is a follow-up call made to all consulting providers,andarethesecalls ThisAre tool telephoneprovides a reference consultations for nurse practitioners documented seeking to evaluate basicinthe risk exposurespatient. Thehealthcare content is not intendedinformation to be a complete listing of all actions needed to address the subject matter, but rather is a means ofdocumented? initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs.record, The informationincluding containedboth hereinthe is notconsultant’s intended to establishname any standardand theof care,information serve as professionalreceived? advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individualDo staff situation check compassing with a review patients relevant lawsto anddetermine regulations. CNA if assumesreferral no responsibility recommendations for the consequences have of the use or nonuse of this information. Are specialists asked to submit a written report following consultations,using been followed,andarethesecallsandpatientresponsesdocumented? astandardreferralformthatisretainedinthepatienthealthcareinformationrecord? Is the patient informed of potential consequences of refusing to follow Does the referral form include space for the following basic information, through on a referral,andisthisactiondocumentedinthepatienthealthcare ataminimum: CNA NURSE PRACTITIONER Claim Report: 4th Edition PART 1 66 informationrecord? --Thepatient’sname? Is a written referral form required from all outside providerswhorefer --Thediagnosticsofferedtothespecialistandthedatetheywerecollected? patientstoone’spractice? --Theprimarypractitioner’sdiagnosis? Are practitioners alerted to after-hours calls from patientsneedingemergency Thetreatmentcompletedtodate? car-e-orinformation? Thetestorprocedurethespecialistisexpectedtocomplete? Ar-e- all attempts to reach a patient by telephone noted,includingthenumber called--Theandinformationmessageleft?neededfromthespecialist? ThisAr toole allprovides patient a reference telephone for nurse practitioners calls seeking documented to evaluate basicby risk practitionersexposures. The contentand is notstaf intendedf? to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a riskIs management a system directive in place from CNA. for No documentingorganization or individual follow-up should act upon appointment this information without reminders, appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individualwithvisit situationnotifications compassing a reviewrecorded relevant lawsin andthe regulations.patient CNA healthcarassumes no responsibilityeinformation for the consequencesrecord ofor the use or nonuse of this information. inafollow-upvisitlog? Are canceled and missed follow-up appointments monitoredandnotedin thepatienthealthcareinformationrecord? CNA AND NSO RISK CNACONTROL NURSE SELF-ASSESSMENT PRACTITIONER CHECKLISTClaim Report FOR: 4th NURSE Edition PRACTITIONERS PART 1 66 3 Is there a written policy addressing patients who miss scheduled follow-up appointments on a routine basis,andarepatientsinformedofthispolicy?

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA NURSE PRACTITIONER Claim Report: 4th Edition PART 1 67 October 9, 2017 8:05 AM

Documenting Patient Healthcare Information (continued) Yes No Comments/Action Plan Is a follow-up call made to all consulting providers,andarethesecalls documented? Do staff check with patients to determine if referral recommendations have been followed,andarethesecallsandpatientresponsesdocumented? Is the patient informed of potential consequences of refusing to follow through on a referral,andisthisactiondocumentedinthepatienthealthcare informationrecord? Is a written referral form required from all outside providerswhorefer patientstoone’spractice? Are practitioners alerted to after-hours calls from patientsneedingemergency careorinformation? Are all attempts to reach a patient by telephone noted,includingthenumber calledandmessageleft? Are all patient telephone calls documentedbypractitionersandstaff? October 9, 2017 8:05 AM Is a system in place for documenting follow-up appointment reminders, withvisitnotificationsrecordedinthepatienthealthcareinformationrecordor inDocumentingafollow-up visitPatientlog? Healthcare Information (continued) Yes No Comments/Action Plan IsAre every canceled visit documentedand missed follow-up in the patient appointments healthcare monitored informationand recordnotedandin arethethepatientfollowinghealthcareactionsinformationandinformationrecord?noted: Is -there-Date a inwrittenfull(month/day/year) policy addressingofexamination patients whoor treatment?miss scheduled follow-up appointments on a routine basis,andarepatientsinformedofthispolicy? --Reviewofmedicalandmedicationhistory? October 9, 2017 8:05 AM This tool-- Chiefprovides apatient reference forcomplaint? nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs.- The-Clinical informationfindings contained hereinand is observations,not intended to establishboth any standardnormal of care,and serveabnormal? as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a riskInformed management directiveConsent/Informed from CNA. No organization Refusal or individual should act upon this information without appropriate professional adviceYes, includingNo advice ofComments/Action legal counsel, given after a thorough Plan examination of the individual--Diagnosis? situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information. Do nurse practitioners know the basic elements of informed consent,aswell Receiptofinformedconsent? as-informed- refusal? Referral,ifnecessary? Do- -nurse practitioners know when an informed consent discussion is necessary, Prescriptionsandover-the-countermedications? as-well- asthespecialcircumstancesinwhichitmaybeomitted? Postoperativeandfollow-upinstructions? Do- -nurse practitioners conduct a face-to-face discussion with the patient, allotting--Plansasformuchnexttimevisit?asisneededtoaskandanswerquestions? DoDoes nurse the practitionerspatient healthcare answer information all questions recordtothe notepatient’s the rationalesatisfaction? for not following a previously documented plan of careandotherimportantmedical Is informed consent documented in the patient healthcare information record decisions? assoonasitisobtained? Are canceled appointments and no-shows documentedinthepatienthealth- Are written informed consent forms utilized,andifso,dothey… careinformationrecord,aswellasattemptstocontactthepatientandreschedule Haveapatient-friendlyandeasy-to-understandtitle? appointments?-- Describethenatureoftheproposedtreatmentanditslikelybenefits? Is -evidence- of patient satisfaction or dissatisfaction documented,including Listpossiblealternativetreatmentsaswellastheirrisksandbenefits? specific-- complaintsandconcerns,aswellasfavorablecomments? Notepotentialcomplications/risks? Are-- instances of noncompliance documented,aswellasdiscussionswith patients--Useregardingthesimplestconsequentlanguagerisks?possible? Are-- treatmentAllowforcustomization complicationsas documented,necessary? aswellasunusualoccurrencesand Whencorrective possible,actions dotaken? nurse practitioners give the informed consent form to the patientAre all pertinentprior to the discussions beginning documented, of treatment,whethersotheinpatientpersonhasortimebytelephone?tothink aboutthedecision? Are all referrals to specialists and consultants documentedinthepatient Ishealthcare the signedinformation informedrecord? consent form placed in the healthcare information record,andisacopygiventothepatient? Is the patient given written, customized postoperative instructions,andare Ifthese a patientinstructions declinesdocumented? recommendations, is this refusal documentedinthe healthcareinformationrecord? Are telephone consultations documentedinthepatienthealthcareinformation Arerecord, theincluding risks and bothpotentialtheconsultant’s consequencesname ofand refusalthe toinformation follow CNArecommendationsreceived? NURSE PRACTITIONER Claim Report: 4th Edition PART 1 67 explained to reluctant patients in writinganddocumentedinthehealthcare Are specialists asked to submit a written report following consultations,using informationrecord? astandardreferralformthatisretainedinthepatienthealthcareinformationrecord? ThisDoes tool provides the areferral reference for form nurse practitioners include seeking space to evaluate for the basic riskfollowing exposures. The basic content information,is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs.ata Theminimum: information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual--The situationpatient’s compassingname? a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information. --Thediagnosticsofferedtothespecialistandthedatetheywerecollected? --Theprimarypractitioner’sdiagnosis? --Thetreatmentcompletedtodate? --Thetestorprocedurethespecialistisexpectedtocomplete? --Theinformationneededfromthespecialist?

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA AND NSO RISK CNACONTROL NURSE SELF-ASSESSMENT PRACTITIONER CHECKLISTClaim Report FOR: 4th NURSE Edition PRACTITIONERS PART 1 66 4

CNA NURSE PRACTITIONER Claim Report: 4th Edition PART 1 68 October 9, 2017 8:05 AM

Patient Education Yes No Comments/Action Plan Are barriers to communication assessed and documented inthepatient healthcareinformationrecord,includinglowhealthliteracy,cognitiveimpairment andlimitedEnglishproficiency? Are qualified and credentialed interpreters availablewhenrequired? Is the “teach-back” technique usedtoensureunderstandingofproposed treatments,servicesandprocedures–e�g�,notonlyaskingpatientsiftheyhave anyquestionsabouttheirmedications,butalsorequestingthattheydescribe intheirownwordshowtotakethem? Is use of the teach-back technique documentedinthepatienthealthcare informationrecord? Are patients asked to explain in everyday language the medical information they have been given,including: --Diagnosisorhealthproblem? --Recommendedtreatmentorprocedure? --Risks,benefits,andalternativespertainingtotherecommended treatmentorprocedure? --Patientresponsibilitiesassociatedwiththerecommendedtreatment? Are patients asked to repeat back critical instructions,andistheirresponse notedinthepatienthealthcareinformationrecord?Forexample,“It is important that we remain on the same page regarding your recovery. Can you tell me in your own words what an infected wound looks like and what you would do if you observed signs of infection?”

Barriers To Compliance Yes No Comments/Action Plan Are underlying factors affecting compliance explored with patientsina nonjudgmentalmanner?Forexample,“It sounds as if you may be concerned about the medication’s possible side effects. Is that why you have not taken it as prescribed?” Do providers strive to achieve a mutually acceptable plan of care with hesitant patients,usingthefollowingstrategies: --Identifyingandrecognizingspecificpatientconcerns,suchasthe out-of-pocketcostsofaprocedure? --Identifyingpracticalorlogisticaldifficultiesthatmayhindercompliance, suchaslackofreliabletransportationtoandfromthepractice? --Encouragingpatientstogetasecondopinion,ifdesired? --Takingthetimetoexplainthepotentialconsequencesofnotcomplying withrecommendations?

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA AND NSO RISK CONTROLCNA NURSE SELF-ASSESSMENT PRACTITIONER CHECKLIST Claim Report FOR: 4th NURSE Edition PRACTITIONERS PART 1 69 5 October 9, 2017 8:05 AM

Patient Management Yes No Comments/Action Plan Do patient healthcare information records note the individuals whom patients rely upontomeettheirgeneralhealthcareneeds(e�g�,spouse,relatives,paid caregivers,friends,etc�)? Are written protocols established and implemented for patient management issues,including… --Narcoticuseandgeneralpainmanagementindrug-seekingpatients? --Appointmentorprocedurecancellations? --Unacceptablebehavior,suchasbelligerentvoice-mailmessages, yellingorcursingatstaff? --After-hourspatientmanagement? --Refusaltoconsenttorecommendedtreatment? --Noncompliancewithrecommendationsregardingmedications orlifestylechanges? Are patients reminded of upcoming appointments,includingreferralsand laboratoryvisits,andareremindersdocumentedinthepatientcarerecord? Are electronic alerts usedtoremindpatientswithahistoryofnoncompliance aboutscreeningandmonitoringrequirements? Are blind or otherwise impaired patients informed of subscription services that,viawirelessdevices,deliverreminderstotakemedicationsorperformother self-careactivities? Are follow-up and referral appointments scheduled and entered in the computer systembeforepatientsleavethefacility? Does written policy require documentation of no-shows,aswellasappropriate follow-up? Is there a written policy for terminating the provider-patient relationship ifthepatientischronicallynoncompliant?

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA AND NSO RISK CNACONTROL NURSE SELF-ASSESSMENT PRACTITIONER CHECKLISTClaim Report FOR: 4th NURSE Edition PRACTITIONERS PART 1 706 October 9, 2017 8:05 AM

Medication Safety* Yes No Comments/Action Plan Are all patient/caregiver concerns and questions about a prescribed medication addressed by the NP,includingthedrug’sappearance,aswellasthepatient’s abilitytoaffordandswallowitandfollowdrugadministrationdirections? Is all necessary patient identification information entered into the system before any medications are prescribed,including… --Fullname(includingpreferredprefix)? --Gender? --Dateofbirth? --? --Allergies? --Physicaladdress? --Alltelephonenumbers(e�g�,home,cell,business)? --Alternatemeansofcontact(e�g�,emailaddress,emergencycontactperson)? Is the current medications list reviewed, entered into the computer system and updated at each encounter,anddoesitinclude… --Prescriptions,includingdose,frequencyandroute? --Over-the-counterproducts? --Immunizations,includingvaccinationdates? --Vitaminsandotherdietarysupplements? --Homeopathicremedies,herbalproductsandotheralternativemedicines? Are telephone orders read back to the nurse practitionerbythepharmacist toconfirmtheiraccuracy? Is opioid prescribing strictly supervised, incompliancewiththestate’s prescriptiondrugmonitoringprogram? Are allergies documented,includingadescriptionofpastreactions? Are NPs and others in the practice trained to prevent medical errorsby applyingcontinuousqualityimprovementtechniques? Are NPs and others in the practice trained to report adverse drug reactions to the U.S. Food and Drug Administration,aswellasfollowinternalreporting protocols?

* Additional medication safety-related risk control self-assessment questions can be found in the “2017 ISMP Medication Safety Self Assessment for Community/Ambulatory Pharmacy.”

This tool provides a reference for nurse practitioners seeking to evaluate basic risk exposures. The content is not intended to be a complete listing of all actions needed to address the subject matter, but rather is a means of initiating internal discussion and self-examination. Your clinical procedures and risks may be different from those addressed herein, and you may wish to modify the tool to suit your individual practice and patient/client needs. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. The statements expressed do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation compassing a review relevant laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

CNA AND NSO RISK CONTROLCNA NURSE SELF-ASSESSMENT PRACTITIONER CHECKLIST Claim Report FOR: 4thNURSE Edition PRACTITIONERS PART 1 717 1100 Virginia Drive, Suite 250 333 South Wabash Avenue Fort Washington, PA 19034 Chicago, IL 60604 1.800.247.1500 www.nso.com 1.888.600.4776 www.cna.com

In addition to this publication, CNA and Nurses Service Or ganization (NSO) have produced numerous studies and articles that provide useful risk control information on topics relevant to nurse practitioners, as well as information relating to nurse practitioner professional liability insurance, at www.nso.com. These publications are also available by contacting CNA at 1.888.600.4776 or at www.cna.com.

The information, examples and suggestions have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situation. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2017 CNA. All rights reserved.

Nurses Service Organization (NSO) is the nation’s largest administrator of professional liability insurance coverage to individual nursing professionals. Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., an affiliate of Aon Corporation. For more information about NSO, or to inquire about professional liability insurance for nursing professionals, please contact NSO at 1.800.247.1500 or visit NSO online at www.nso.com.

Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc. (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc. (CA 0G94493); Aon Direct Insurance Administrators and Berkely Insurance Agency; and in NY, AIS Affinity Insurance Agency.

X-12916-1017

CNA AND NSO RISK CONTROL SELF-ASSESSMENT CHECKLIST FOR NURSE PRACTITIONERS 8