Page 11 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

execute a Refusal of Treatment form or make other appropriate

documentation.

Consider the following case:

CASE STUDY

A 50-year-old male patient underwent PTCA with stent,

complicated by RLE ischemia. He was returned to the cath lab.
After discharge, he was seen by PCP five days later for

ecchymosis. Four days later, the patient was readmitted with
acute stent thrombosis and bleeding. The patient expired. The

family sued the PCP and the cardiologist. In a deposition, the PCP

recalled the office visit and described the patient as being in a
hurry, requesting more pain medication and refusing additional

testing. The PCP did not document physical findings or the

patient’s refusal to consider additional testing. The case was
settled before trial.

Some additional examples of informed refusal claims against
SVMIC insured physicians include the following medical situations:

 A lymph node biopsy revealed metastatic squamous cell

carcinoma, but the patient refused radiation or
chemotherapy.

 A patient in premature labor experienced hemorrhage from

placental abruption but delayed consent for emergency C-

section for 10 minutes, resulting in delivery of a stillborn
infant.

 An EKG showed a bundle branch blockage, but the patient
refused follow-up treatment and cardiology consult.

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