Avoid these common errors in self-defense!
Thorough documentation is an essential tool of risk management. The onus—always—is on you.
Don’t disregard a questionable finding
When a test reveals an incidental suspicious finding—such as a shadow on a chest radiograph or an abnormality in blood work—the surgeon is responsible for following up, even if someone else ordered the test. You cannot ignore such a finding or assume the internist or PCP will follow up.
In addition, you should notify the patient about any such problem—even if it is unrelated to the reason the patient is seeing you. If the finding is incidental to the surgery, you must tell the PCP and follow up with the patient.
We have seen situations in which diagnostic test results fall through the cracks. Cases that arise from such a lapse are, ultimately, indefensible and often involve shared responsibility or liability among the surgeon, the physician who ordered the test, and the primary care physician. Never put yourself in a position to have to say, later: “I saw that but didn’t do anything about it.”
Telephone calls to and from patients: A right way to keep records
Documenting the date, time, and content of your telephone calls with patients demonstrates competent management and provides evidence of your decision making in all aspects of patients’ care. Some guidelines:
- Always include the date, time, and content of the call.
- Document your advice to patients to come in for a follow-up appointment.
- Don’t let medical assistants offer independent medical advice. They should repeat your orders and nothing more. The notes should read, “Per Dr. Jones, advised patient to do X, Y, and Z,” and should be initialed by the staff member who spoke with the patient.
- Document follow-up calls—whether you’re on the telephone in the middle of the night or during office hours. Write in the chart what you advised the patient to do and what her response was. Don’t give any patient the ability to say, “If the doctor had told me that, I would have gone to the emergency room”—when that is precisely what you said, but you can’t prove it.
- Document missed appointments, especially postop, in the chart—not in the appointment book. Such chart notes show that the patient interrupted the treatment that you recommended. Later, if the patient claims, “My injury is a direct result of the physician’s failure to provide proper care,” you’ll be able to respond: “I can demonstrate that I asked you to return, but that you failed your appointment here, rescheduled it there, and made it almost impossible for us to provide good care.”
- Establish a mechanism for notifying patients to return after a postop no-show. Ensure that your staff returns the chart to you so that you can decide what to do next.
Be meticulous about informed consent
In documenting informed consent, your language reveals your attitude toward the process. For example, we’ve often heard physicians say “I consented the patient” instead of “the patient gave me her informed consent.”
I recommend that you document your discussion with the patient in the chart, instead of relying on a form. Typically, this is done on the history and physical, the consultation report, or the initial progress notes. Note which family members are present during the discussion: At some point, counsel may need to ask family members what they heard or what you said.
Sometimes we see informed consent discussions documented in the operative report. This is inappropriate because it represents an event after the fact. Informed consent that has been recorded after the procedure can look self-serving to a third-party observer—such as a plaintiff’s attorney. (For more advice on obtaining informed consent, see Part 4 of this series, upcoming in the June 2007 issue.)
Write it down when a patient won’t cooperate
Likewise, I recommend that you document informed refusal—whether or not the state in which you practice requires you to do so. This can dispel difficulties that may arise when a patient claims she would have consented to the surgery if you had discussed the risks properly with her. (See the March 2007 installment of this series for an in-depth look at informed refusal.)
Avoid a casual approach to patient education
Another deficiency that we encounter again and again is physicians’ failure to document their efforts to educate patients, orally and by written word. Consider that you and your peers spend a lot of time educating patients about surgical and nonsurgical options; discussing their comorbidities, smoking, and weight; and asking them to review videos, read pamphlets, and fill out lengthy questionnaires. Then, many fail to document their efforts!
Save those e-mail messages!
Physicians’ offices increasingly use e-mail to communicate with patients. Saving those e-mail messages is as important as documenting a telephone call in the chart.
Print both the patient’s e-mail and your response to it. Keep those pages in the chart to provide a running history of your management.
