Failing to listen, communicate, and spend adequate time with patients
Research on why patients sue physicians has repeatedly shown that basic interpersonal skills such as listening and showing respect can be just as important as clinical skills in preventing lawsuits. (1)
Eye contact and attentive listening are important and can go a long way in building a relationship with the patient. And patients who have a good relationship with their physicians will be less likely to sue if a bad outcome occurs.
Another key factor in patient satisfaction involves the quality of time spent with the physician, not just the quantity. Short visits can be effective if you will sit down, listen to the patient, ask the appropriate questions, and allow patients time to ask questions. If you spend the entire visit with your hand on the doorknob, patients may feel rushed and may not give you complete information.
Right now, you are rightfully asking “How can I improve a patient’s perception of a satisfactory visit when time is limited?” Here are some tips.
- When possible, schedule the length of the appointment based on patient needs.
- During the appointment, spend time connecting with patients on a personal level.
- Before patients are taken to the exam room, ask them to complete a form that prompts them to state the reason for their visit.
Documentation
Accurate, legible, and complete documentation can be your best defense against a malpractice claim or a board action. What would your medical records look like to another physician, a plaintiff’s attorney, or a jury? Poor documentation practices can delay care and may signal to others that you are careless or do not care to follow your patients closely.
Poor documentation alone will not generally send a patient to an attorney, but could lead to a suit once the attorney sees the records. Poor documentation also makes the case more difficult to defend.
Medical boards will discipline physicians if their medical records are incomplete or illegible. Make sure your documentation — including electronic templates — includes your state medical board’s required elements: the reason for the encounter; the relevant history; the physical exam findings; prior diagnostic test results; and the patient’s progress, including response to treatment or change in diagnosis.
EHR templates
A common problem area for physicians involves the use of electronic templates within the electronic health record (EHR). The use of templates is widespread and can save the physician time in documentation. But using templates can also create the impression that the notes are incomplete or inaccurate
When using preformatted text or templates, edit entries to ensure the record accurately reflects the care delivered. Inconsistent information in the record, due to prepopulated text, can be problematic in the event of a claim or board action.
It is also important to update each encounter note to reflect the patient’s current symptoms and to check for unintended system defaults to “normal” or “negative.” The review of systems or exam should not conflict with the history of present illness or chief complaint.
Alterations
Another documentation practice to avoid involves “correcting” medical records after an unexpected outcome or notice of a claim. Altering the medical record after the event — even if you believe the information will assist in your defense — is detrimental.
An addendum to the medical record may be allowed if done in a timely manner and clearly identified as such. Include the date and time, a reference to the date and time of the actual encounter, reason for the addendum, the added information, and author’s signature. Also, any changes made in an EHR will likely be “time stamped” electronically.
Follow up
Establishing and maintaining strong follow up and communication policies and procedures can help enhance patient care.
A physician who orders testing is responsible for reviewing results when received; documenting his or her review in the medical record; and initiating appropriate follow up.
A problem for many practices is the lack of a clearly defined tracking system for managing test results used across facilities, offices, laboratories, and other institutions. While tracking systems will vary from practice to practice, there are four basic steps physicians can follow to help ensure test results are managed properly.
- Track tests until results are received.
- Notify patients of the results.
- Document that the notification occurred.
- Ensure that patients with abnormal results receive recommended follow-up care.
Instituting a clear system for effective patient follow up is also recommended. In establishing policies and procedures, consider the following.
- Prioritize test results with “urgent,” “critical,” “action needed,” or “pending results.” A coding system may heighten awareness and trigger appropriate follow up.
- Standardize and simplify processes by using checklists, flow sheets, or tracking systems.
- Adopt technologies that employ built-in systems such as reminders, alerts, and the flagging of documentation issues. Recognize that these types of systems are only effective if there is a commitment to use them.
- Avoid using the “no news is good news” approach for dealing with test results. Abnormal test results can be sent to the wrong office, misplaced, or filed without physician review.
- Consider enlisting your patients in helping you track test results. Encourage them to call if they have not received their test results within a previously agreed upon timeline. Another way to enlist patients in their own care is to hold them accountable to their follow-up appointments. Emphasize the importance of follow up and encourage them to keep their appointments.
While involving patients in their own care can help overall outcomes, their involvement does not relieve the physician of his or her responsibility to follow up.
Medication errors
When patients experience adverse reactions to or lack of benefit from medications, lawsuits can result. These suits allege such errors as: failing to check the patient’s chart when prescribing medication; prescribing improper dosages; failing to consider and advise patients of potential side effects or interactions with other drugs; prescribing drugs outside the physician’s specialty; and prescribing drugs for non-patients.
To avoid allegations related to improper prescribing, consider the following guidelines.
- Check the patient’s medical record when prescribing or refilling a medication. Request that the patient come for an office visit, if appropriate, before authorizing a refill.
- In the patient’s chart, record medications and allergies in a central location or be sure to include all medications in the electronic record. Update this information at each visit.
- Provide the patient with information about the drug, and document discussions and any handouts given.
- Be familiar with the drug prescribed. Refer the patient to a specialist if he or she requires a drug that is outside your scope of practice.
- When prescribing drugs off-label or in dosages exceeding those recommended, document your rationale. Also document that you discussed the risks and benefits of the treatment with the patient.
- When a patient calls with reports of unusual symptoms, the prescribing physician should be alerted.
- If a pharmacy calls to question a prescription, check the original order.
- Make sure any handwritten prescriptions are legible and that dosages are correctly noted.
- Review any applicable state laws for requirements regarding opioid prescribing. Most states have passed laws that require increased monitoring of patients who receive controlled medications. Reviewing a patient’s prescription history via monitoring programs before prescribing controlled substances is recommended.
Source
1. Huntington B, Kuhn N. Communication gaffes: a root cause of malpractice claims. Proceedings of Baylor University Medical Center. 2003 Apr; 16(2): 157–161. doi: 10.1080/08998280.2003.11927898 .
