Page 15 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

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

given explicit direction and notice that important information

is missing. The patient should be further instructed to contact
the physician at a time and date certain to get the results of

the test, provided he or she has not been contacted first. This
conversation must be accurately and thoroughly documented

in the chart, along with the patient’s contact information so
the patient can be reached immediately if the test result is

significant.

If the patient insists on leaving the hospital against medical
advice, careful documentation is critical to a successful defense

in the event of a lawsuit. Memorialize the conversation between
physician and patient regarding pending test results, and

clearly delineate the specific advice and warnings given to the
patient. This documentation must be placed in the medical

record in a prompt and timely fashion. Contact numbers should
be obtained and documented. It should also be documented

that the patient was instructed to contact the physician for the
test results by a certain time and date, provided the patient

had not been contacted with the results before the appointed
time and date. The fact that the patient acknowledged the

risks involved and insisted on leaving the hospital regardless
of medical advice must be documented in the medical record,

and the patient must be instructed to sign and date the note. If
the patient refuses to sign, “signature refused” should be written

across the signature line. This will evidence every attempt was
made to provide critical information to an uncooperative and

unreasonable patient. When test results come back, the time
and date of each and every attempt to contact the patient

must be documented, especially when the result is clinically
significant.

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