Page 6 - Part Two Risk Reduction Series - Documentation
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SVMIC Risk Reduction Series: Documentation
transportation, forgot or don’t understand the care instructions or
have other barriers to adherence. Document your inquiry and not
just by stating that the “patient is noncompliant” in the record; for
example, “Ms. Whitehead has missed three consecutive
appointments for required lab testing. She states she ‘just doesn’t
want to come in for labs’ but expects me to continue her
medication. After explaining the importance of lab monitoring
again, she states she will keep her appointment tomorrow. She
understands repeatedly missing appointments negatively affects
her care and may result in discharging her from my practice.”
Informed Consent
Allegations of failure to obtain informed consent are typical in
medical malpractice claims. Virtually every specialty practice
renders some form of medical care necessitating informed
consent. Take for example the following case:
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