Page 12 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

A healthcare provider should completely document the extent

and details of a physical examination or history, discharge
instructions, and telephone calls. The note should describe

what took place, what you were thinking, and what you told
the patient. Document your phone conversations with other

physicians to include name, date, and time of call, as well as the
essence of the exchange.

As noted earlier, patients sometimes insist on being discharged

against medical advice while an important test report is still
pending, and obviously, this is a problem. A patient who refuses

further treatment at the hospital does not relieve a physician
of follow-up responsibility unless the physician has carefully

documented a good faith effort to impress upon the patient the
potential seriousness of the situation and arranged to contact

the patient when the report comes back. A patient refusing
further treatment is a serious situation, and as such, any and all

documentation must be accurate and present the full picture.

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