A primary, if not preeminent, goal of every physician in practice today is the avoidance of a lawsuit for medical malpractice. In pursuit of that goal, the hard reality of practice dictates that risk management of medical malpractice claims falls directly upon, and is ever present with, every physician throughout each moment of rendering care. Understanding where the highest risk areas lie, and taking affirmative and aggressive measures to risk manage those prioritized threats, will provide physicians with the greatest protection toward avoiding a claim and/or being prepared to defend, and defeat, a claim that arises in spite of these measures.
- 1Creating Medical Records That Are Not “Self-Protective” The initial “triage” of a potential medical malpractice claim is normally carried out by a physician or nurse retained by the attorneys representing the patient. These attorneys, seeking a financial recovery/gain, are not desirous of investing large sums of capital, resources and time into a claim which presents with a strong, defensible set of medical records. However, records that are insufficient in detailing the actual care and treatment rendered, illegible, self-conflicting with other practitioners and/or fail to defend the physician will encourage a claim.
- 2Failing To Pursue a Patient’s Medical History In initiating care, many physicians (or their staff upon patient intake) “lower their guard” and fail to aggressively pursue and/or document critical information regarding a patient’s medical history – such as prior or concurrent care (especially medications), conditions unrelated to the presenting complaint and/or names of other treating doctors. Moreover, securing the identity and contact information of other past or present treating physicians, and thereafter securing records from those physicians and/or communicating prospective care with that physician, will dramatically strengthen the defensibility of the care rendered.
- 3Ignoring Past Developments in Subsequent Interactions Many physicians will properly make note of a new complaint or a new clinical presentation yet then fail to revisit those developments in subsequent interactions with the patient. In certain cases, diagnostic studies are also properly ordered to evaluate the new development yet the physician will fail to document his or her review of and reaction to those studies (returned post-visit) and any measures undertaken in response (or the lack of any need to undertake any measures).
- 4Failing To Adopt, and Abide by, a “Tickler” System Throughout patient care, countless diagnostic, laboratory and/or radiological tests are ordered by treating and/or consulting physicians. Logically, these tests are completed post-visit or consult and the results are provided thereafter. Unfortunately, many practices are failing to adopt a strict and uniform “tickler system” to insure that these tests are received, evaluated, acted upon – and that each responsive measure is properly documented within the medical record. The structure of such a “tickler system” can vary-;, however, the core should be (a) track ordered tests and referrals (b) ascertain why reports are not received on a timely basis and secure same. Once the report is secured, the system/protocol should also require that no test can be “filed” by the practice until it is reviewed (and that review is documented) by the ordering physician.
- 5Breakdowns in Communications The treatment of patients today involves a growing number of practitioners in an increasing myriad of roles (treating physicians, specialists, consulting physicians, care extenders, etc.). Proper “cross-communication” between those carrying out these roles can actually serve to increase the defensibility of a potential claim; however, the failure to properly communicat