[PrvPracNP] important topic-Documenting when you're on call

[GIN11153 at aol.com]

    Malpractice Consult
    <PUBLICATIONDATE  Apr 7,  2006 <AUTHOR>  By: _Lee  J. Johnson, JD_ 
(http://www.memag.com/memag/author/authorInfo.jsp?id=6592)    Medical  Economics     
      
Q. On a weekend when I was  home on call, I spoke with a patient who reported 
swelling in his leg.  Since his condition didn't sound serious, I advised him 
to come to my  office early Monday morning, but I never documented the phone 
call.   
Unfortunately, he never showed up at  the office that Monday, and I was too 
busy to notice. A few days later, he  was rushed to the ED where they found a 
pulmonary embolism. Now he's suing  me for malpractice, based on delayed 
diagnosis.  
Can I be held liable based on that  phone call? Am I really required to 
document such calls even when I'm at  home on my day off, and even if I don't 
actually see the patient?   


A. You're not required to document it,  but you certainly should, since 
taking patient calls at home is the same  as practicing medicine in the office. In 
both settings, good documentation  is the best defense against liability; its 
absence can often ruin the  defense.  
The outcome of this case will depend in  part on a credibility battle between 
you and the patient. He'll claim that  he told you his condition was very 
bad, while you'll claim that he  reported only minor complaints that didn't call 
for immediate treatment.   
What you need is some crucial evidence  that you don't have: a record of the 
phone call, including the nature of  the complaint and the advice you gave, or 
your progress note with that  information in the patient's chart. Without 
that evidence, you have  nothing to counter the patient's claim.  
With nothing to support your memory, a  jury may not believe your account. 
They may reasonably feel that your  recall of past events is likely to be biased 
in your own favor. A  contemporaneous note, however, written when the events 
were still fresh in  your mind, would be less subject to bias, and therefore 
stronger evidence  for your defense.  
Another common scenario in cases  alleging failure to diagnose involves a 
patient who claims that she called  several times to report symptoms, while the 
doctor denies receiving those  calls. If the doctor has an established pattern 
of recording such calls on  a message pad and then copying them into the 
chart, his defense will be  much stronger. They can also be filed in the chart with 
a reference in the  progress record: "See phone message 2/3/06."  
If you're on call for a colleague and  one of his patients calls, make sure 
the doctor gets a timely report of  the conversation, particularly if you 
ordered medication or recommended a  follow-up visit or treatment. Keep a record of 
the call, and the fact that  you notified him.  
Have some telephone message pads  printed up, preferably with duplicate 
copies, and keep them in your home.  The message slips should contain spaces for 
the following information:  date, time, caller's name (or patient's name if 
other than the caller),  complaint, action taken, advice given, medication advised 
or prescribed,  and your signature.  
If a call involves a patient's  treatment, copy or put the message slip into 
her chart as soon as possible  afterward. If it concerns the care of a 
hospital patient, enter it in the  hospital record. Train your office staff to use 
those message slips as  well, and to give them to you so that you can enter the 
information in  your progress  notes
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