1. Have a tickler file of things that need to be followed up. A file box with 3 x 5 cards and dividers by month will do. Stick a label imprinted with patient name and other identifying information on a 3 x 5 card, note what needs to be followed up, and drop the card in the box behind the month during which follow-up is needed. Check the box at least monthly, and do what is stated on each card. This small system can prevent abnormals--Pap smears, mammograms--from falling through the cracks, even if the patient fails to follow-up.

2. Use preprinted forms wherever feasible. For example, a gyn exam form can include boxes to check for such entries as "Breasts symmetrical, nipples extroverted, without skin changes or lesions," and NPs can have more complete documentation in less time.

3. Attend seminars which keep you up-to-date on the standards of care in your area of practice.

4. Pay attention to data which show the most fertile areas for lawsuits for physicians. It is likely that the data also will pertain to NPs.

For example, the top 15 conditions that lead to malpractice claims, as reported by the Physicians Insurers Association of America are:

1. Brain-damaged infant
2. Breast cancer
3. Pregnancy
4. Acute myocardial infarction
5. Displacement of intervertebral disc
6. Cancer of bronchus or lung
7. Fracture of femur
8. Appendicitis
9. Cataracts
10. Colon and rectal cancer
11. Back disorders, lumbago, sciatica
12. Abdominal and pelvic symptoms
13. Sterilization
14. Elective plastic surgery
15. Coronary atherosclerosis

Among procedures involved in malpractice claims, the top 14 were:

1. Diagnostic interview, evaluation or consultation
2. Prescription of medication
3. Diagnostic radiology, excluding CT scan
4. Surgery, joints, excluding spinal fusion
5. General physical exam
6. Surgery, uterus
7. Miscellaneous manual exams and non-operative procedures
8. C-section deliveries
9. Surgery, skin, excluding grafts
10. General anesthesia
11. Injections and vaccinations
12. Manually assisted deliveries
13. Surgery, fallopian tubes, ovaries
14. Surgery, blood vessels, excluding heart

4. Develop a system for getting angry patients to a staff member who has been trained in managing difficult situations.

This tip is excerpted from the March issue of The Gold Sheet, a monthly newsletter published by the Law Office of Carolyn Buppert. The Gold Sheet covers the latest news on quality for NPs. For a 12-month subscription, send a check for $25 to The Gold Sheet, Law Office of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD 21403. A companion newsletter, The Green Sheet, offers the latest information on NP compensation and reimbursement.

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