Page 10 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

with regard to healthcare and many patients elect to refuse

treatment based on a number of factors such as cost,
health literacy, fear of a particular procedure, and cultural or

religious considerations. When this is the case, it’s important
to document the patient’s reasons for refusal as well as the

physician’s discussion of the indications for the treatment, their
consequences of refusal, and any follow-up conversations and

educational materials provided to the patient. Documenting
a patient’s refusal to undergo a test or imaging study is also

important. Does a patient’s concern over cost cause that patient
to refuse certain tests or make a patient reluctant to obtain

follow-up appointments? If so, consider getting the patient to
execute a refusal of treatment form or make other appropriate

documentation.

Consider the following case:

C A S E S T U DY

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.

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