Documenting Noncompliance Won't Protect You Anymore

Mark Crane


November 12, 2012

In This Article

Biggest Mistakes in Noncompliance Documentation

Many physicians falsely assume that they need to write copious notes to protect themselves from lawsuits. Attorneys and risk managers disagree. Explaining your rationale for treatment and the patient's response needn't take that long.

If you didn't chart something, the perception in front of a jury is that it didn't happen. That's why negative as well as positive results should be charted. Include enough detail so that someone reading your notes years later can understand your thinking.

Which of these 2 notes is likely to be more effective in court? "Patient in apparent good health" or "I reviewed all systems. Patient denies any complaints." "The first statement is a subjective perception," says James Griffith. "The second says that (1) you asked the patient whether he or she was having any problems and (2) the patient said nothing was wrong. It doesn't take any more time to document the second statement."

Do physicians actually know whether patients are complying with their instructions? Every physician needs a reliable clinical tracking system to identify patients who fail to keep scheduled appointments for tests and consultation with specialists. Do you call patients who've missed their appointments? How do you know whether the patient actually saw the gastroenterologist you referred him to?

"Failure to maintain reliable clinical tracking systems is one of the most frequently cited problems in malpractice cases where there is an allegation of delay in diagnosis or failure to supervise care," said Georgette Samaritan.

Why an "At Risk" Letter Is a Must

It isn't enough protection for physicians to note in their charts that the patient isn't compliant. Juries want to know whether you reached out to him to let him how serious the problem is. "We recommend sending an 'at risk' letter, letting the patients know the full implications of noncompliance," said James Saxton. "It can be 3 short paragraphs: 'You failed to come in for your scheduled appointment. Here are the implications of what could happen. Please call the office as soon as possible.'"

"We've found improved compliance once that letter is sent," he said. "If the patient seeks out an attorney, that letter in the file can discourage the filing of a lawsuit. And if the lawsuit is filed, it's powerful evidence when you put a blowup on a screen showing that the patient received that letter."

Many physicians are asking patients to sign a checklist of discharge instructions, stating that they understand and will abide by them, he adds.