Page 28 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

given to obtaining a biopsy of the mass. There is no mention of

discussion with the patient that the mass could be cancer.

This tragic example serves to illustrate the importance of inquiring

about, documenting and acting upon a patient’s family history. The
increasing availability of DNA and genome testing for several

genetically-linked diseases has become a factor in claims alleging

failure to diagnose such conditions. According to the American

Medical Association, a properly collected family history can:

 Identify whether a patient has a higher risk for a disease.

 Help the healthcare practitioner recommend treatments or
other options to reduce a patient’s risk of disease.

 Provide early warning signs of disease.

The history should be detailed including:

 First, Second and Third-degree relatives

 Age for all relatives (age at time of death for the deceased)

 Ethnicity (some genetic diseases are more common in
certain ethnic groups)

 Presence of chronic diseases

Document reminders in the medical record if additional screening

is required at defined intervals.

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