APMA News - November/December 2012 - (Page 82)

Insurance Advisor By William F. Munsey, DPM Documentation and Release Forms A reader writes, “I had a recent scare from a situation with a patient that could well have led to a malpractice action. The case involved infection management of a noncompliant diabetic patient. Needless to say, I was upset when the patient’s lawyer requested his records. Fortunately, because of my good documentation, the lawyer was convinced that not only had I managed the patient in an appropriate manner, but also that the patient’s noncompliance had contributed to her situation. “A risk management pointer from [the Podiatry Insurance Company of America] resulted in our office implementing should include documentation of the patient’s name, the date the test was ordered, the name of the lab/facility where the test was performed, the date the results were received, the doctor’s initials and the date he or she reviewed the results, the date of the patient’s notification, and any follow-up action needed. Document any changes in the patient’s condition in his or her medical record and address the change appropriately by further examination, diagnostic testing, referral to a specialist, follow-up examination, etc. If you feel no action is necessary, document your rationale for that decision. Promptly address a patient’s complaint of unusual or severe pain. Instruct the patient to come to the office immediately or to go to the emergency department for evaluation and document your instructions in the patient’s medical record. Tracking systems for laboratory and diagnostic tests should ensure that the results are received, seen, and evaluated by the doctor; commented on in the chart; and acted upon appropriately. policy changes for documentation—particularly in lab report management. I am convinced those changes were a deciding factor in the dismissal of the case.” The reader’s remarks speak volumes. The following risk management pointers from the Podiatry Insurance Company of America (PICA) are worth repeating: Develop and implement a fail-safe system to track diagnostic test results. Failure to do the appropriate diagnostic tests can result in diagnostic delay and lead to a bad outcome for the patient. Potential risks of a faulty tracking system include: QUESTION: A teenage boy was seen as a new patient in my office for the removal of plantar verruca. His grandfather brought him to the office and stated he would sign a release form for me to curette the verruca. Can the grandfather legally sign the consent form for the procedure? ANSWER: Only the boy’s parent or legal guardian can sign the consent form. In order for you to perform the procedure, you could call the parent or legal guardian and obtain telephonic permission to perform the procedure and for pertinent medical information to be relayed to the grandfather. The phone call should be documented in the patient’s record. For visits that require more than general information, or for a follow-up appointment that requires communication or patient education, schedule the appointment at a time when a parent or legal guardian will be present. The phone call or conversation during which the appointment is made should have a witness on the line with the doctor, and the call should be documented in the patient’s chart. n Contact Dr. Munsey at wfmunseydpm@gmail.com. • • • • • an ordered test not being performed; test results not getting back to the office; a test being filed in the patient’s chart without review by the doctor; results being filed in the wrong patient’s chart; and failure to notify the patient of test results. Tracking systems for laboratory and diagnostic tests should ensure that the results are received, seen, and evaluated by the doctor; commented on in the chart; and acted upon appropriately. The tracking system 82 APMA News November/December 2012

Table of Contents for the Digital Edition of APMA News - November/December 2012

APMA News - November/December 2012
President’s Message
Contents
United States of Diabetes
Corporate Partners and Members: A History of Generosity
Tradition of Leadership: APMA Executive Directors Move Podiatric Medicine Forward
100 Years of Chiropody History in the UK: A Personal View
Annual Scientifi c Meeting Registration Form
2012 Podiatric Practice Survey: Age and Gender by Practice Arrangement Type
APMA By the Decade: 2002–2012
Reimbursement
Federal Advocacy Forum
Cosponsors to the Equity and Access for Podiatric Physicians Under Medicaid Act
APMAPAC Contributions in the 2011–12 Election Year
APMAPAC Chair Report
IT Consultant
Website Wisdom
Technofi
Small Business 101
CPME Update
APMA All Stars
Resolutions Deadlines
In Short
Worthy of Note
Affi liates Corner
Insurance Advisor
New Members
Death Notices
APMAPAC Update
Classified Advertising
Dates to Remember
Advertising Index
10 Questions
Your APMA

APMA News - November/December 2012

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