Six Top Malpractice Risks in Primary Care

Mark E. Crane


September 14, 2010

In This Article

Malpractice: Documentation and Follow-up Failure

Diagnosis errors comprise a major cause of lawsuits in primary care. However, once a lawsuit occurs, the chief factor that can make a case difficult to defend involves poor or careless documentation.

Physicians often lose or have to settle defensible cases because their documentation is inadequate. A malpractice case may occur years after you've seen the patient, who'll claim a perfect memory while you may not even recall him or her. Often, your documentation is the major defense.

Busy doctors may complain that they don't have enough time to fully document each patient encounter, but adequate documentation needn't take that long and is essential to providing a good defense of your actions. "You can spend an extra minute or two now versus the chance of facing years of misery and worry defending a malpractice suit a few years down the road," says Paul Gabel.

Some patients may be in denial about their conditions. "They have selective hearing," says Gabel. "Then when something bad happens, they don't recall how much you emphasized the need for a test. But if the chart is well documented, juries understand that patients go into denial and will find for the physician."

Charting Can Save You

How you chart can keep you out of a courtroom. "The word 'deny' should be used more frequently," says James Griffith. "The patient denies fever, pain, etc. What that tells a jury or a plaintiff's attorney is that you asked the question and the patient said he didn't have it. There's a need to write down exactly what the patient says. It's also important to jot down your thinking process, why you ordered a test or decided not to."

Every office needs a system to track test results and consultant reports. "No record should ever be filed away until the physician initials it," says Griffith. "This has been standard risk management advice for decades but it happens all the time. I'm amazed that too many physicians don't read or comprehend the tests they've ordered. I've seen blood tests with H's or L's (to signify high or low) all over the place that the physician didn't even address."

Treatment guidelines promoted by different medical groups can vary widely. "Malpractice litigation is about the gray areas of medicine, without an absolute right or wrong," says Roland A. Goertz, MD, a family physician in Waco, Texas, and President-elect of the American Academy of Family Physicians. "But there are some absolutes. If you order a test, there must be 100% assurance that you'll follow up on it. There is no margin of error. Every office needs a system to make sure that tests get reviewed. If they are abnormal, the doctor must see them."


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