Following these tips can help you reduce risk and keep your patients safe.
Review your tracking systems to ensure follow-up and patient notification for all test results, especially for mammograms and Pap smears. All test results must be seen and initialed by the physician and communicated to the patient before being placed in the medical record. Your tracking system should include provider/staff notification when a result is not received and should not depend on opening the patient’s record or on a return appointment. Your patients should not assume that “no news is good news” and should expect to hear from you on the results of all tests.
Education materials help raise patients’ awareness about issues that might affect their reproductive health. Keep in mind, however, that the functional education level of your patient population can affect the quality of your medical care. Address the health literacy needs of all patients by choosing educational literature written at an eighth-grade reading level, or lower if your patient population speaks English as a second language or has limited educational experience. Preview and recommend specific online educational videos, if applicable, as another way to inform your patients. Always encourage your patients to understand their medical issues, what action they need to take, and why it is important for them to follow their health plan.
The American College of Obstetricians and Gynecologists (ACOG) recognizes colonoscopy as the standard for colon cancer screening. Document the medical record with all exam and screening recommendations and any patient refusals to follow them.
If information is deemed important enough to be included in the prenatal record template you use, it should be filled in consistently with appropriate documentation. Failure to do so may be interpreted as a breach of your own adopted standard.
Discuss labor and delivery issues with your patient in the third trimester. When your patient has time to make informed decisions about her care, have a detailed discussion during an office visit about the use of oxytocin for augmentation, vacuum or forceps assistance, episiotomy, and the possibility of shoulder dystocia or C-section. During labor is not the ideal time to obtain informed consent. Document all discussions in the prenatal record so that the information sent to the hospital is available to staff and any covering physician during your patient’s labor and delivery treatment course.
Ask your patient to discuss her birth plan with you far in advance of her admission for delivery. In the event a patient might deliver while you are not available, clearly communicate your patients’ wishes to the covering physician(s) before signing out. If you know that one of your partners does not agree with any portion of your patient’s birth plan (for example, using a birthing tub or rejecting fetal monitoring), communicate that information to your patient early in the pregnancy. This will give her an opportunity to meet with your partner to resolve any issues or choose another practice.
Clearly document the following elements in the medical record:
Encourage OB safety drills at your practice facility that focus on response times, staffing, and resources available for emergency situations. Drills do not have to utilize high-level simulation technology if it is not available, but they should include both staff and physicians in order to practice optimum teamwork coordination.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.