Malpractice. The word stops a clinician in her tracks. We all face the potential threat of a malpractice suit, and should be as vigilant as possible in our clinical setting to prevent such an unfortunate situation.
The temptation, of course, is to ask patients to sign something similar to this disclaimer:
I understand that I will not construe that the service I received from you is a 'diagnosis'. Instead, I agree that you have merely rendered an opinion, subject to all qualifications as may be necessary to decrease your liability for this opinion in a court of law. I agree that you do not guarantee any medication, treatment, procedure or recommendation you have given me at this visit as having any effect upon my condition. I agree that any recommendation or statement you have made to me was purely for conversational effect and should not be understood as instruction, direction or advice. With my signature I waive any and all present and future right to file for any compensation claims against you, your facility or staff.
Signed Patient
A Disclaimer Alternative
I have found an excellent book to help avoid malpractice. 1 I heartily endorse the following points to help decrease your odds of ending up in court:
Know the "red flag" complaints and conditions. The top 5 conditions that clinicians most often miss are breast cancer, lung cancer, myocardial infarction, appendicitis, and colon or rectal cancer. Pay particular attention to red flag conditions such as a breast lump, nipple discharge, breast rash, enlarged lymph node, chest or shoulder pain, and lower abdominal pain.
Rule out what you cannot afford to miss. Identify the worst condition on the differential diagnosis, gather the necessary information to rule it in or out, tell the patient of the possibility of this diagnosis, and document what you have done.
Know the risk factors that call for screening tests. Know the recommended tests for ruling out diseases associated with your geographic area. Know the expected screening tests specific to a patient based upon his age, gender, occupation, habits, family history and exposures.
Record the tests and follow-up. Each time a test is ordered, a time bomb is set in motion. Defuse it by properly notifying the patient of the results, setting up a tickler file until the condition is resolved, diagnosed, treated or the patient has refused treatment. Document everything.
Revisit old problems until resolved. If you find a 'problem' during a visit, note it on the Problem List and ask about it (and chart the patient's response) at each subsequent visit until resolved.
Practice vigilance with all prescriptions. Triple-check the legibility, spelling, dose, frequency, and duration of the script. Describe and chart all discussion of side effects, risks of the medication, and precautions to watch for.
Audit your charts for mistakes or omissions. If you find an omission, write an addendum with the current date and reason for the additional entry. Never cross out or alter an entry, or try to squeeze in extra information as if you had written it earlier. You risk huge liability if your documentation fails to reflect the actual care and services provided to the patient.
If the patient doesn't need something, don't order it. Avoid the possibility of doing more harm than good by taking a minimalist approach to treatment.
Remember, if it's not in the chart, it didn't happen. Be particularly cautious with high-risk patients and situations. Be certain that your charting is accurate, complete and timely. Log every phone call, test ordered and referral made. Follow through appropriately. Adhering to each of these malpractice prevention tips may avoid the necessity of having patients sign the above disclaimer at every visit.
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