Documentation of physician impairment and inappropriate behavior
Documentation is imperative to a successful investigation and resolution of physician impairment and/or inappropriate behavior. It is critical in demonstrating patterns of behavior. In cases that lead to disciplinary actions, documentation is necessary to establish cause for the action. Your behavior reporting form should be designed to include:
- Date, time, and place of the incident.
- Name of the person filing the complaint and any other witnesses to the incident. (The person filing the complaint may wish to remain anonymous.)
- Name of the patient or patient family members, if involved.
- A description of the occurrence.
- The effect of the behavior on patient care and/or hospital operations.
- Any actions taken to remedy the situation.
- Department chair documentation of discussion with the physician.
- Department chair documentation of resolution.
- Physician’s response to complaint. (Physician may or may not want to document a response)
- Signature of physician leaders involved, and the physician named in the complaint.
It is also important to place a time limit on the filing of a complaint. It is much more effective to deal with an incident soon after its occurrence than to try to investigate something that happened a few weeks or even months before. Sometimes people are hesitant to file a complaint, and may stew about it for weeks before they work up the courage to do anything. It may also be considered unfair to the physician to bring up something that happened so long ago that they doesn’t remember the incident. Hospital staff and the medical staff should be comfortable with the process so that they feel able to file a complaint without fear of retaliation.
Behavior complaints are confidential and should be maintained in the physician’s quality file or other secure file designated for this purpose. Typically, either medical staff services or the quality department is the keeper of the reports. Your policy should designate the physician leaders who may have access to the report. The CEO should also have access to review the report.