Today, I had to complete an online course for my malpractice insurer. No, it was not punitive, my employer gets a discount on my insurance rate if I complete the course. I, of course was annoyed to have to complete an online quiz on my afternoon off. But, much to my surprise, I actually did learn something. Let me share.
Document, Document, Document!
You must record details of your patient visits. Even if everything is normal. Make sure you document a complete history, physical, review of systems and exam findings for each patient. One takeaway from the course- make sure to complete a good family history. Admittedly, I often skip over the family history portion of my chart. It is seemingly insignificant and often leads to patients telling me long stories about their half cousin who isn’t technically related and had some weird medical condition. Or, they tell me about their great grandmother who has so many medical conditions if I were to document them all I would have to write a five page addendum to their chart. You need to document family histories on a patient’s siblings and parents. No more, no less. Medical conditions such as lung cancer, breast cancer and colorectal cancer are often not documented on patient charts. A family history of these conditions puts your patient more at risk. These conditions must be documented not only to help you provide better preventative care for your patient but also to protect yourself.
Get Patients Their Test Results
This can be difficult no matter your practice environment. Test results come in from the lab or the imaging center to the fax machine. A co-worker spills coffee on said fax machine… test set out to dry on the floor. The clinic cleaning crew comes at night sees a bunch of paper scraps on the floor… goodbye test results. More likely, patient doesn’t answer the phone when called back about test results, you set test results to the side and forget about them. Or, something falls through the cracks at the imaging center. Ultrasound results showing that a patient has uterine cancer don’t make it to your clinic, you and the patient don’t find out until it is too late. Tell your patients to expect a call about all test results EVEN IF THEY ARE NORMAL. This way, your patients will call you to check up on results rather than assuming since they did not get called everything is “OK”. When you do contact (or attempt to contact) a patient about results write down time, date, if you were able to get in touch with the patient and what you advised them to do based on their results. Make this a permanent copy of their medical record. You are ultimately responsible for delivering testing information to your patients.
Part of being a healthcare provider is being thorough. This means close follow up and documentation. In a busy medical practice, this is often the first corner that gets cut. Don’t let this happen to you!