Mr M, a 54-year-old man, has been going to the same internal medicine practice for almost 20 years. The practice was staffed by several physicians, physician assistants, and nurse practitioners. Mr M typically saw Mr P, a 48-year-old physician assistant, for his appointments.

Mr M presented to the office for an assessment of a lump in his right groin. After an examination conducted by Mr P, the patient underwent a computed tomography (CT) scan.

Results from the scan show an enlarged inguinal lymph node. Although receipt of the results was documented in the patient’s record, there was no indication in the record that the patient had been notified about the results or what the next steps should be.

Two months later, at Mr M’s next appointment, the office’s electronic health record system was down and Mr P could not access the patient’s chart for review. At that appointment, Mr M did not mention the groin lump, and Mr P, who saw many patients each day, did not remember it.

During the next 10 months, the patient came in for a few visits with Mr P, but never mentioned the groin lump. The following year, Mr M returned to the practice and saw a nurse practitioner, Ms N. The clinician noted that the groin mass had increased in size and was now painful. Ms N referred Mr M to a general surgeon who performed a biopsy of the enlarged lymph node. The biopsy revealed stage 3 Hodgkin lymphoma.

When Mr P heard about Mr. M’s diagnosis, he looked at the patient’s record and realized he had not documented the follow-up of the original CT scan. Figuring he could remedy this by adding in the information to the record now, Mr P added a note to Mr M’s health record stating that he had told the patient about the CT results 2 years earlier and instructed him to follow-up with a surgeon. However, there was no referral form in the record or any indication from the time of the CT scan that the results had been conveyed to the patient.

After Mr M was told by an oncologist that his prognosis was worse than it would have been had the cancer been discovered 2 years earlier, he decided to seek the counsel of an attorney. After reviewing the patient’s records, the attorney filed a lawsuit against Mr P, his supervising physician, and the practice.