Claims related to a missed or delayed diagnosis are the fastest-growing types of claims but they can be avoided. Let's take a look at how to protect yourself, and your patients.
Posted in Risk Management on Friday, August 30, 2019
The Importance of Capturing Information
A recent report indicates that 34% of malpractice cases are related to delayed or inaccurate diagnoses. Missed test results can lead to diagnostic error, a delay in diagnosis and potentially a delay in treatment.
These types of cases are the most common, catastrophic and costly. They are also avoidable. A well-designed and applied tracking system can help protect both your patients and your practice.
Claims related to a missed or delayed diagnosis are the fastest-growing types of claims and can be avoidable.
Another potential tracking issue is when you recommend a patient see a consultant or refer them to another provider. It can be difficult to get the patient to take that step. You are responsible for communicating the need for this referral/consult and educating the patient accordingly. Following up with the patient and the consultant/other provider is just as important as following up on test results due to potential allegations from a delay in diagnosis. It is important to document this conversation, and your own follow-up steps, to protect yourself should the patient not comply with your recommendation.
These are just two examples of why you should establish a tracking system to capture tests, referrals and consults for everyone in your practice.
What You Need to Track
Tracking is important to your practice from a patient safety, risk management and defense perspective. Providers are responsible for explaining:
- What tests, referrals and consults are being ordered
- Why they are being ordered
- When the patient should expect the results or pursue the referral/consult
- How those results and the follow-up care will be provided
- The actual results
- The date, time and method of how the results were conveyed
- Any referrals or follow-up instructions, and when and how that information was conveyed
Contacting Patients with Test Results
More and more we hear practices only contact patients with abnormal results. We understand you are busy and your staff is stretched, and making phone calls can take time. However, based on best practices established by credible organizations like JCAHO (Joint Commission) and AHRQ (Agency for Healthcare Research and Quality), we believe you should contact patients with all results, not just abnormal results.
Test Results and Referrals
It is important to know that if a patient is referred to another specialty, results from an ordered test will be sent to that provider. There are two reasons for this: first and foremost, it will allow continuity of care for the patient. Second, it prevents repetition of a test that has been ordered prior to the patient seeing the referral. This is important because some insurance companies will not pay for a repeated test, unless there is documentation provided that shows a legitimate reason for that specific test to be repeated. If the insurance company won’t pay for it, then the patient would have to. This could add a financial burden to the patient.
The primary doctor should have the patient sign a medical release form so the patient’s note, test results, etc., can be sent to the specialty doctor the patient is being referred to.
Documenting Outstanding Results
When dealing with outstanding test, referral or consult results, the patient should remain active in the tracking system until one of two potential outcomes occurs:
- Documentation of Informed Refusal1 to follow the provider’s recommendation for additional tests/referral/consult or
- Documentation that the patient has been contacted with the results and provided with advice and/or instructions
How to Contact the Patient
One question that commonly arises is, “How many times should we attempt to contact the patient?”
It depends on the severity of the situation. For anything requiring further action (abnormal test results, referral to another provider) we recommend trying to call the patient three times. If you don’t reach them, try calling at different times of the day or days of the week.
If you are still unable to reach the patient, consider sending a letter, both via regular mail and via certified letter (with delivery receipt) requesting they contact your office immediately. Document your actions along with the delivery receipt from the letter.
If the situation is dire, you can request a well check by the local police department.
When a patient fails to keep a referral or consultant appointment, request the consultant provide written confirmation of the fact that the patient did not come for their appointment. This follow-up letter should be provided by the consultant as soon as it is obvious the patient will not be following up.
If the patient continues to disregard your recommendation for tests, referrals or consults, you must make the decision as to whether to continue with the patient in your care. First, try to understand why the patient is refusing to comply with your recommendation.
If a patient is not following your advice, your documentation needs to be at a level better than you think is sufficient
Doctor/Patient Relationship
The doctor/patient relationship is built on trust. If the trust is broken by the patient not following your advice, your documentation needs to be at a level better than you think is sufficient: document each and every conversation, using actual patient statements with quotation marks indicating direct quotes. You need to make it clear to anyone who might pick up your records that you had the conversations regarding the risks, benefits and alternatives of having/not having the recommended tests/referrals/ consults.
Informed Refusal
Have the patient sign an “Informed Refusal” form which clearly indicates the consequences of not having the recommended tests/referral/consult. If you are using an EMR which uses “smart phrases” be sure to edit the phrase so that it is specific to the patient and their situation.
Should you need to dismiss the patient, it is important to follow a proper dismissal protocol to prevent a claim of abandonment. Contact your state board and notify your malpractice company of the dismissal.
Your tracking logs contain PHI (public health information) so they should be maintained consistent with other practice documentation containing such, and if/when destroyed, destroyed consistent with HIPAA rules.
Creating a Policy for Tracking
A tracking system doesn’t have to be elaborate, but it does need to be used consistently. The most efficient way to ensure this is to create and document a policy with procedures so everyone in the practice is on the same page. Diligence in tracking and documenting is critical from a risk management standpoint.
Some things to note:
- Simple policies and procedures are more likely to be followed than complex ones.
- For example, have one designated staff person enter all the tests/consults/referrals ordered at the end of each day and when results are received. However, it is good to have all staff cross-trained in this area and to have the system centrally located for accessibility.
- For consults and referrals, request that the other provider advise you if the patient fails to schedule or make the appointment so follow up can be made. All attempts to contact the patient should be documented.
- Include in your procedures:
- How to contact patients and how that will be documented
- A time frame for notifying patients of results and next steps
- How you will handle missed or delayed results/reports (e.g., contact the facility and alert the requesting provider)
- A plan for repeat testing due to abnormal/clinically significant results (define abnormal/clinically significant)
- A plan for handling critical (life threatening) results (define critical/life threatening)
- The tracking form can be as simple as a notebook with a log where a staff member logs in the test(s)/consults/referrals ordered and then checks them off when the expected outcomes are achieved.
- Note that this is a multi-step task: Just noting the order and not the outcome is not sufficient.
- Taking the position of having the patient call for results or return to the office will not excuse you of liability.
- Your tracking system can be part of your EMR.
- Be sure your system alerts the provider to outstanding results without having to open the patient’s chart.
- Confirm reports can be run, which pinpoint outstanding reports.
Tracking logs should be kept 7 to 10 years for adults, or 7 to 10 years after a child turns 18.
Sample Tracking Log
Using Tracking Systems Effectively
For tracking systems to be used effectively, all test results and consultant reports received should be initialed and dated by the ordering provider prior to being filed into your system. This simple step illustrates that you have indeed reviewed the results. It is important to recognize that the provider who ordered the test is responsible for the follow up. If the ordering provider is not available to receive the results, a backup plan should be in place. This backup provider should have the authority to take immediate action should the results be such that immediate action is necessary.
The backup provider can be a chiropractor covering the practice during the primary DC’s absence.
In a multiple disciplinary practice an MD, PA or NP could cover for the chiropractor. If that is the case, a policy needs to be developed stating who will cover the practice when the doctor is out.
Recommended Best Practices
Contacting the patient with all results is the recommended practice rather than following the “no news is good news” rule or “forced follow-up.” The provider should document:
- How the patient was notified of the results (phone, letter, in person, etc.)
- Date and time of notification
- In the case of abnormal results:
- Make the follow-up testing appointments immediately after communicating the abnormal result
- Be sure patient understands the urgency of the retesting
- Do not leave results on voicemail, in an email or via text message
- Advice and instructions provided to the patient
- When dealing with referrals and consults, clearly define for the patient the role of each provider for coordinating care/monitoring treatment and ensuring follow up
These guidelines for tracking patient information, test results, referrals and consults are intended to keep you and your practice safe while also keeping the patient informed.