Running a clinic, outpatient centre or medical practice involves a range of legal obligations. They concern not only the provision of healthcare services, but also medical records, patient rights, personal data protection, cooperation with staff and the facility’s internal procedures.

In practice, problems often result from documents or solutions that have been used in the facility for years but have not been kept up to date. A legal audit of a medical facility makes it possible to check such areas, find potential irregularities and put them in order before they become a source of dispute or a problem during an inspection.

Our firm carries out legal audits of clinics, practices and other entities performing healthcare activity. We tailor the scope of the audit to the type of facility, the services offered and the way it operates.

What do we check during a legal audit?

Depending on the facility’s needs, the audit may cover, among other things:

• documentation provided to patients,
• consent forms for healthcare services,
• rules for informing patients about treatment,
• authorisations concerning records and health information,
• rules for keeping and making medical records available,
• compliance with patient rights,
• the facility’s organisational regulations,
• personal data protection documentation,
• contracts with doctors and other staff,
• contracts with entities cooperating with the facility,
• procedures for patient complaints and claims,
• information published on the facility’s website and in its materials,
• other documents and procedures related to the medical activity.

We do not apply one identical audit scope to every facility. A small doctor’s practice needs different solutions from a dental clinic, and different again from a larger facility employing dozens of specialists.

Medical records

Medical records are one of the most important areas of a facility’s operation.

They should not only be kept correctly, but also properly stored, secured and made available to patients and other authorised persons.

During the audit, we check, among other things, the procedures used for records, authorisation forms and the way patient requests are handled.

We also pay attention to solutions that may cause problems only in the event of a dispute. Properly kept records matter not only for the treatment process, but also for the ability to show how the services were actually provided.

Patient consent and the duty to inform

A patient’s signature on a form does not always mean that the issue of consent has been properly regulated.

What matters is both the content of the documents used and the way the patient is informed about their health, the proposed treatment, possible methods and the consequences of a given service.

As part of the audit, we analyse the consent forms used by the facility and other documents given to the patient.

We check whether they match the type of services provided and whether they need to be supplemented or updated.

Patient rights

Medical facilities are obliged to respect patient rights at every stage of providing services.

This concerns, among other things, the right to information, medical records, consent, respect for privacy and dignity and confidentiality of patient information.

During the audit we check whether the procedures and documents used in the facility allow these rights to be properly respected in daily practice.

We also analyse how more problematic situations are handled – for example a request to release records, providing information to a close relative or a conflict between a patient and staff.

Protection of patients’ personal data

Medical facilities process health data that requires special protection.

That is why the audit may also cover documentation and procedures related to personal data protection and GDPR.

We check, among other things, the rules of access to data, staff authorisations, documentation on cooperation with external entities and the way the required information is provided to patients.

We also analyse solutions used for online patient registration, web forms and the use of external IT systems, if the facility uses them.

Contracts with medical staff

A facility’s legal risks do not concern only relations with patients.

The way cooperation with doctors, nurses, physiotherapists and other team members is regulated is also important.

We analyse the contracts used in terms of, among other things:

• the scope of duties,
• the liability of the parties,
• the rules of settlement,
• the duty of confidentiality,
• the use of the facility’s equipment and infrastructure,
• keeping records,
• ending the cooperation,
• other provisions important for the specific business model.

A well-drafted contract should reflect how the cooperation works in reality, rather than merely formally regulating the basic issues.

Procedures in case of a patient claim

A patient claim may arise even in a properly functioning facility.

What matters then is not only the course of the treatment itself, but also how the facility responds after receiving a complaint, a demand for payment or information about a possible dispute.

As part of the audit, we can check whether the facility has appropriate procedures for such situations.

We help establish, among other things:

• who should be responsible for contact in the matter,
• which documents should be secured,
• how to respond to the patient’s demand,
• when the matter should be reported to the insurer,
• how to act so as not to hinder the later defence of the facility’s interests.

A good procedure helps avoid actions taken under the influence of emotions and ensures a consistent response from the whole team.

Website and information about services

The audit may also cover information published by the facility on its website, social media or other materials aimed at patients.

We check whether the way services, specialists and the facility’s activity are presented complies with applicable regulations and whether the published content creates unnecessary legal risk.

Registration rules, appointment cancellation rules, contact forms and other documents used in communication with patients may also be analysed.

What does a legal audit of a medical facility look like?

We start the audit by learning how the facility operates and establishing the areas to be analysed.

We then review the documents and procedures provided, comparing them with current legal requirements and the way they are applied in practice.

After completing the analysis, we point out the irregularities and risk areas identified and present specific proposals for changes.

Depending on the scope of cooperation, we can also prepare or correct documents, forms and procedures that need updating.

As a result, the audit does not end with simply pointing out problems – it can lead directly to putting them in order and implementing appropriate solutions.

When is a legal audit worth carrying out?

An audit may be useful not only when a problem has already arisen in the facility.

It is worth considering, among other things:

• before starting medical activity,
• after several years of operation without updating documentation,
• after changing the scope of services,
• before opening another facility,
• when increasing staff numbers,
• after organisational or ownership changes,
• after receiving a patient complaint or claim,
• before an expected inspection,
• after significant changes in the law.

The best time to find weak points in documentation is when it does not yet have to be used in a dispute.

Legal audit of a clinic – security instead of acting after the fact

The purpose of a legal audit is not to create more documents that nobody uses later.

It is above all about checking whether the solutions used by the facility reflect how it actually operates and whether they provide an adequate level of legal security.

Our firm has experience both in providing services to medical entities and in conducting disputes concerning medical liability and patient rights. That is why, during the audit, we also pay attention to elements that may become important only when a claim arises.

Our aim is to find risk early – before it becomes a problem for the facility, its owner or its staff.