Signing Off...Are There Concerns?
By Kristen M. Lambert, Esq., MSW, LICSW, CPRHM, FASHRM
Vice President, Psychiatric and Professional Liability Risk Management Group

Whether you are a supervising physician, an attending, medical director or in a senior position to other psychiatrists or behavioral health providers, at times, you may be asked to “sign off” on records. These may include treatment plans, discharge summaries as well as other records. As a part of your hospital or clinic’s procedure, you may be given a large stack of documents at the end of the week or end of the month with which to sign off. Due to the volume and time limitations, you do not read what you are signing – it is just part of your role to sign off. Are there liability issues with doing so?

This is a tricky answer but the short answer is there are liability considerations when you sign off on a record. If an adverse issue occurs and a board of medicine complaint or a lawsuit is brought, even if you did not see the patient or have any involvement in the care and treatment, when your signature appears in the patient’s record, you could potentially become involved in the legal action either as a witness or a defendant. By virtue of your signature appearing in the record, an attorney representing the plaintiff will likely explore what your role was in the care and did you have any supervising responsibilities. You may be added as a defendant at the outset of the case or as the case progresses and evidence develops, and you may be added as a defendant or called as a witness to testify at a deposition or trial. Whether you are ultimately held liable is up to the court to decide.

Even though you may not have any direct involvement with the patient when in this role, there may still be liability exposure. Under the legal doctrine of respondeat superior (translated “let the master answer for the deeds of his servant”), a psychiatrist may be held liable for those he/she supervises. Psychiatrists must be aware of their particular state regulations, along with the supervisee’s level of education, experience and training in order to determine the amount and type of supervision that may be necessary.

In addition to vicarious liability, other theories of liability can include negligent hiring and retention and negligent supervision. For more information, see the American Psychiatric Association resource documents, “Guidelines for Psychiatrists in Consultative, Supervisory or Collaborative Relationships with Nonphysician Clinicians” and “Risk Management and Liability in Integrated Care Models.”1,2

There are also other issues that could arise when signing off, such as billing issues. Recently, there was a specific case in North Carolina involving a nurse practitioner who signed off on documents involving alleged Medicaid kickbacks. According to the case, a nurse practitioner agreed to sign off on orders authorizing various Medicaid recipients to receive outpatient behavioral health services. However, she never evaluated the patients or made any clinical assessment of whether the services were medically necessary. The nurse practitioner also accepted funds in exchange for signing the orders. As a result of this matter, the nurse practitioner agreed to a plea deal including surrendering her license.3

Conclusion

There are many issues to consider if asked to “sign off” on records. At the end of the day, it is your license to practice medicine. It is important to be aware of what you are signing. Should you have questions, consult a risk management professional or attorney.      

RISK MANAGEMENT TIPS

  • Understand your state and federal laws and regulations. Regulations and laws vary among states.
  • Be aware of your ethical guidelines and obligations. In addition, it is important to review the APA resource document on collaborative, supervisory and consultative roles with non-physician clinicians.
  • If your hospital or clinic asks that you sign off on documents, know what your responsibilities include. It is recommended that you discuss the request with the person you report to and prior to engaging in the practice. In the event of an adverse outcome, it will be important that you are aware of your role in signing off.
  • Ensure there are clear delineations of responsibility between team members. Know who is supervising whom.
  • Know your employment contractual obligations and whether your contract has language concerning your role and responsibilities over patient care and whether you are obligated to sign off on others’ treatment plans/documents.
  • If part of an organization, be aware of your organization’s policies and procedures and whether there are provisions concerning supervision.
  • Effectively communicate with team members who you supervise. Consider how you are communicating (written or verbal) to ensure that potential gaps in communication are minimized.
Kristen_Author

About the Author

Kristen Lambert serves as the lead for risk management for professional liability policyholders and specialty programs. She specializes in risk management services for psychiatric providers and the behavioral health areas. Prior to joining Allied World, Kristen practiced as an attorney focusing on health law matters including medical malpractice defense. Kristen is admitted to the bars in Massachusetts and Connecticut and the U.S. District Court in Massachusetts. Kristen also has worked as a clinical social worker in community and tertiary hospitals as well as community mental health settings.

 

 

1 American Psychiatric Association, “Guidelines for Psychiatrists in Consultative, Supervisory, or Collaborative Relationships with Nonmedical Therapist,” Am J Psychiatry 137: 1489-1491, (1980); Bland, D.A., Lambert, K., Raney, L. APA Resource Document, “Risk Management and Liability in Integrated Care Models,” Am J Psych 171:5, May 2014.

2 Raney, L. (Ed), et al, Integrated Care: Working at the Interface of Primary Care and Behavioral Health, APPI, (2014).

3 https://www.justice.gov/usao-ednc/pr/nurse-practitioner-admits-receiving-kickbacks-signing-orders-medicaid-services

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