Page 29 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

The Importance of Documenting Family History

C A S E S T U DY

A 32-year-old female patient presented to OB with

presence of palpable breast mass which ultimately was
found to be malignant. Upon medical record review, the
description of the breast mass was poor. The only

statement describing the mass was that it was located at

the 4 o’clock position. There was no mention of the
patient’s menstrual history or family history with respect
to cancer. The patient’s mother and maternal grandmother

both had breast cancer. No consideration was given to

obtaining a biopsy of the mass. There was no mention of
discussion with the patient that the mass could be cancer.

This tragic example serves to illustrate the importance of

inquiring about, documenting, and acting upon a patient’s family
history. The increasing availability of DNA and genome testing

for several genetically linked diseases has become a factor in
claims alleging failure to diagnose such conditions. According

to the American Medical Association, a properly collected family
history can:

• Identify whether a patient has a higher risk for a disease

• Help the healthcare practitioner recommend treatments or
other options to reduce a patient’s risk of disease

• Provide early warning signs of disease

The history should be detailed including:

• First, second, and third-degree relatives

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