Page 5 - Part Two Risk Reduction Series - Documentation
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SVMIC Risk Reduction Series: Documentation
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. Communications including 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 are 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
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