Page 5 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

PART TWO

Documenting Communications with

Patients

A major aspect of documentation involves communicating

with the patient to ensure understanding and agreement
with the treatment plan to facilitate adherence. These crucial

communications include notification of test results, the patient’s
adherence to the treatment plan (keeping appointments,

undergoing recommended tests, seeing consultants), informed
consent, discharge instructions, and providing educational

materials. Documenting such “routine” daily practices and
habits is often neglected, but the documentation may become

crucial to avoiding a negligence claim in the event of an adverse
outcome. One commonly overlooked situation is documenting

missed appointments during which follow-up care or treatment
was to be provided. It is important that the practice have a

procedure to ensure that no-shows and cancellations are
communicated to the treating provider and any follow-up

patient contact attempts are documented in the medical record.
Include the date and time of the call or place a copy of the

missed appointment letter in the patient’s medical record.

Repeated missed appointments as well as other patient non-

adherence may result in a decision to discharge the patient

from practice. Discharging a patient for non-adherence should
be a last resort only after inquiring about and attempting
to resolve barriers to adhering to the treatment plan. Many

patients are unable to afford the medication or recommended

testing, don’t have transportation, forgot or don’t understand
the care instructions, or have other barriers to adherence.

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