Rx for Diagnosis

Relying on memory to complete next steps for diagnostic tasks can mean costly and avoidable errors.

The most frequently cited breakdowns in the diagnostic process from malpractice claims and autopsy data are: failure to order an appropriate diagnostic test, incorrect interpretation of diagnostic test data, and failure to create a proper follow-up plan.

Whether or not electronic health records are used in your office practice, protect yourself by auditing your diagnostic results communication with the following tips. In general:

  • Document all encounters, including patient history and physical examination details.
  • Develop and document a treatment plan.

Communicate the treatment plan with the patient. Confirm that the patient understands his or her responsibilities.

  • Tell them all: Reduce the potential for patient compliance failure by involving the patient’s family when appropriate.
  • Write it down: Give clear, written follow-up instructions to the patient before he or she leaves the office. Include the patient/family in the “redundancy process.”
  • Make the loop and close it: Clearly communicate with the patient when and how he or she will hear diagnostic results. Be clear that if the patient does not hear from you in a specific number of days, he or she should call your office.
  • Communicate effectively: Use the teach-back or Ask Me 3 method.

Also, if you are the primary care physician, make sure that the results are tracked back to your records. If you are the consultant, ensure that your documentation reflects who ordered the consultation and, therefore, who should transmit the report. If you are the hospitalist, make sure you know when the handoff back to the admitting physician is to occur.

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.

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