MPIE Risk Management GEM 2023 (Volume III): Medical Office Self-Assessment Findings and Recommendations

What are your top self-reported risks? In 2022, practice managers completed an MPIE Risk Management Medical Office Self-Assessment. The assessment was based on high-risk areas and areas of concern in ambulatory care. The self-assessment tool focused on those specialties that have a patient-based office setting. Following the self-assessment, all practices received a summary with recommendations and resources to improve their office processes intended to reduce potential risks and improve patient safety.

Overview of the Medical Office Self-Assessment

The focus areas in the self-assessment were identified as problem areas from our claims defense experience, national trends, and the risk hotline. Below are the focus areas:

  • Emergency Preparedness
  • Human Resources
  • Lab Tests and Test Results
  • Medical Records
  • Medication Process
  • Policies and Procedures
  • Infection Control
  • Event Reporting
  • Risk Management

The average score was 80%, the following areas were the top self-identified potential liability risks:

  • Policies and Procedures:
    • Chaperones – only 56% of the practices that completed the self-assessment utilize a chaperone for intimate exams and have signage posted within the practice.
    • Telemedicine Treatment Consent – the COVID pandemic increased the usage of telemedicine visits, and many practices reported not having a policy in place or not understanding the limitations/risks of telemedicine.
    • Social Media – while most practices do not engage on social media with patients, some practices that may engage with patients from time to time do not have a policy in place.
  • Medical Records: Many practices reported on the self-assessments that they are not performing medical record audits for timeliness and quality of documentation, inaccuracies, omissions, or other red flags indicative of poor charting practices.
  • Human Resources: Staff competency with critical skills is not being assessed on an annual basis.

Risk Management Strategies

Policies and Procedures

  • Chaperones: Ensure that the office has a chaperone policy in place during intimate exams. We strongly recommend using chaperones as the default position for all sensitive or intimate exams, and if a patient declines, it should be documented in the medical record.
  • Telemedicine Treatment Consent: Ensure the practice has a policy in place when a patient consents or refuses treatment. Make sure the conversation and the consent or refusal form have been documented and added to the patient’s chart. Telemedicine consents include the same details outlined in standard informed consents. In addition, they expand on the standard informed consent to ensure the patient understands the medium through which care will be delivered and the potential treatment limitations.

Medical Records

Assess medical records for inaccuracies, omissions, or other red flags indicative of poor charting practices on a regular basis. Reviewing medical records quarterly would be ideal, but the practice should aim to do medical record audits at least every six months.

We recommend that practices start with five charts per physician and advanced practice provider (APP). If any of the five charts “fail” the audit, we recommend pulling and reviewing five additional charts for that same provider and audit, as there may be a problem that requires a more significant number of charts to be reviewed; and additional training for the provider should be considered.

Human Resources

Ensure that all staff have critical skills and re-evaluate annually.

As you are aware, as of January 2023, MPIE has been acquired by Constellation Mutual. Please see the publication offered by Constellation, Common Factors: Let’s Get Clinical: What Drives Risk in Clinics, to read more about this topic.  


If you are an employed provider of a healthcare system and have questions on this subject, please consult your organization’s risk management department for advisement as to system policy or protocol.