Page 6 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

Document your inquiry and not just by stating that the “patient

is non-compliant” 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:

C A S E S T U DY

A 10-year-old male with congenital vascular malformation
of upper lip and mouth (AVM) underwent ethanol
sclerosing injections at the regional hospital to dry up the

vessels. He suffered circulation loss in the skin of his lip

resulting in necrosis and requiring reconstructive surgery.
The exact nature of the complication may not have been
specifically explained to the parents. The documentation

reads, “I discussed indications, expectation, and possible

complications of the procedure with the parents and they
accept them.” There was no documentation of any
literature or printed material given to the parents about

this risk. The case was settled.

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