Effective communication and documentation lessen the chances for claims and markedly improve the likelihood for successful defense of a claim.
This article, the third in a three-part series discussing medicolegal issues in urology, focuses on communication and documentation techniques to improve patient care and safety and lower your risk of a lawsuit.
The value of communication
Breakdowns in communication occur at many levels, as this article will point out. Health care providers relay information to each other via oral, written, and electronic means. It is up to the provider to ensure that information is properly and accurately sent and received. We are all responsible for being informed about our patients and clearly understood by our colleagues.
Communicating with patients, colleagues
Good physician-patient communication begins with a comprehensive intake sheet that the patient completes before the initial office visit. Patients also need to update their medical information at subsequent office visits. The patient intake sheet or information from it should become part of the office record. In claims in which the patient and physician disagree about whether a prior medical condition was disclosed, the initial patient intake sheet will be scrutinized for documentation.
Physicians and/or their assistants need to take the time to carefully review the intake sheet with the patient to make sure it is accurate. Many patients are on multiple medications or have drug allergies that are not accurately and completely disclosed to the physician. Claims based on medication errors or interactions can sometimes be eliminated by a careful review of these sections with the patient.
With the advent of electronic charting, the physician or assistant may face the keyboard to input data rather than look the patient in the eye to obtain his or her history. Not only does this degrade the physician-patient relationship, but it also results in suboptimal interpersonal communication, where important facts may be missed.
Consultant notes must be complete and timely in order to provide the information that affects the care provided by others. Claims related to inter-physician communications usually center on complications that could have been avoided had there been good communication between providers.
Also, missed or delayed diagnoses can occur when information from one provider is not relayed to another in an accurate or timely fashion. Urologists who are unaware of significant radiologic or pathologic findings are susceptible to claims in this area. While it is the responsibility of radiologists or pathologists to alert the urologist if a patient has a worrisome finding on an x-ray or a biopsy positive for cancer, they are only required to report the finding on paper or electronically. It is up to the urologist to tell the patient. Urologists must have a system in place to account for all x-rays, lab reports, and biopsies ordered by the doctor.
Urologists may also be involved with claims due to medical or surgical complications that could have been avoided if the urologist had been aware of another provider's evaluation of the patient. This situation can occur when multiple providers are not only adding notes to the hospital chart, but also ordering medications and studies, which can result in adverse events. All hospital patients should have a primary physician or surgeon who is overseeing all medications, studies, and procedures.
Communication between surgeons and operating room personnel has come under close scrutiny this decade. One of The Joint Commission's (TJC) National Patient Safety Goals for 2009 is to "improve the effectiveness of communications among caregivers" (see http://www.thejointcommission.org/). The American College of Surgeons has also published several papers over the past 2 years on the importance of good communication among operating room personnel (Bulletin of the American College of Surgeons 2007; 92:11-6). The "time out" is an important step in verifying the correct patient, procedure, and operative site prior to beginning the operation.