This article is the second in a series of 4 derived from a symposium on malpractice risk management at the 91st Clinical Congress of the American College of Surgeons, San Francisco, Calif, in October 2005. Ms. Dobbs updated her comments in October 2006 and February 2007.
Part 1
March 2007 Informed refusal
James M. Goodman, JD
Part 2 - This issue
Common errors in self-defense
Claudia Dobbs, MA
Part 3
Patient safety as risk management tool
Thomas J. Donnelly, JD
Part 4
Responsibilities in obtaining informed consent
James M. Nelson, JD
In my work analyzing malpractice claims against physicians in 4 states, I (and my colleagues) have found that problems for defendant physicians can often be traced back to their failure to document the care and advice they provide. The 5 most common errors occur (and recur) when physicians are dealing with:
- results of tests
- informed consent
- informed refusal
- patient education
- postop follow-up discussion.
The good news is that, with some attention to detail, you may be able to avoid all these problems. Here is how.
Know the test results
When someone other than the ObGyn surgeon has ordered preoperative tests, that surgeon may say: “I didn’t order them, so I don’t need to review them or sign off on them. The primary care physician (PCP) will tell me whether the patient is ready to have the operation.”
This is a dangerous assumption. It’s your duty to make certain not only that the patient has medical clearance for the operation, but also that the chart proves it. We urge the ObGyn surgeons with whom we work to provide evidence in the chart—by initialing results—that they have reviewed preoperative tests.
If a cardiologist, pulmonologist, or other specialist has been asked to help clear a patient for surgery, the chart should include a consultation report that you review. Add your own notes or initial the report as evidence of your review. Also, document in the chart the details of any telephone communication you had with other physicians on the team.
It goes without saying that prenatal and antepartum records are vital to obstetric care. But those records can, regrettably, increase your liability if you don’t document information clearly or if you fail to monitor what you’ve entered in the record—a necessity made more of a challenge by an often cumbersome layout. Here are helpful hints for maintaining prenatal and antepartum records so that they are useful and reduce your exposure:
Use the record to alert physicians and staff to a high-risk patient. Use red ink or a highlighter or adhere bright stickers to the prenatal record—anything—to draw attention to vital data about risk factors, and thereby prevent injury.
Document sonographic findings and other diagnostic results on the prenatal form. Don’t bury this significant information in the chart—especially when findings are abnormal and must be monitored through the pregnancy. Then draw the reviewer’s eye to findings by, again, using red ink or a highlighter.
Document each prenatal visit completely—just as you would any office visit. Why limit your observations to the many check boxes on the prenatal form or to the one line provided for “Comments”—especially when the patient’s complaints are beyond what you would consider part of a “routine” prenatal examination? Instead, document any extra-routine notes on a separate sheet of paper. These notes should include her subjective complaints and your observations, assessment, and plan for care and follow-up.
Document any discussion you have about informed consent and informed refusal. Memorialize the informed consent communication in a progress note, but avoid documenting informed consent on the single line found on the prenatal form. Use a consent form to supplement your oral discussion.
Clearly document a patient’s informed refusal—whether it be of a significant diagnostic test (HIV, α-fetoprotein, amniocentesis, chorionic villus sampling), of hospital birth (in opting for home birth), and so forth. Ask her to sign a refusal document to supplement your oral discussion.
Make certain the complete prenatal record is sent to the hospital’s labor and delivery suite or operating room before the date of delivery. Some physicians periodically (eg, at the end of the second trimester or the beginning of the third trimester) submit the prenatal record in preparation for a patient’s delivery. This is an excellent practice: It provides pertinent information when a colleague is called to labor and delivery because you are off-call.
Ensure complete documentation of all vital communications and actions. Don’t take shortcuts simply because you’re using the prenatal form to document antepartum care. Document significant telephone calls with patients and consultants, referrals to specialists, missed appointments, and so on.