Legal Background

The case alleged numerous lapses in patient care and failures of communication that ultimately led to a delayed diagnosis and poor patient outcome. Mr M told his attorney that Mr P had never advised him about the results of his CT scan and that he assumed the results were negative. He denied being referred to a surgeon by Mr P. His attorney hired experts to look at the records, and the experts agreed that from the notes, it appeared that Mr M was never originally told about the results and that Mr P’s retroactive note was added solely to protect himself.

Mr. P and his supervising physician met with a defense attorney provided by their malpractice insurance. The attorney had her experts review the records, and they were critical of both Mr P and his supervisor. They identified 5 areas of weakness where the plaintiff could allege that the standard of care had been breached:

  1. The experts concluded that there was no timely documentation that provided evidence that the CT scan results had been discussed or that the patient was told a follow-up plan.
  2. Although Mr. P claimed to have referred the patient to a surgeon after the CT scan, there was no referral documentation, and no formal written referral was made.
  3. The computer failure at the appointment after the CT scan prevented Mr P from accessing the patient’s file; however, the patient subsequently came in several times in the next 10 months, but the groin lump was never addressed, and the CT results were not discussed.
  4. The experts also found fault with the supervising physician, who had apparently signed off on Mr M’s chart but never saw the patient himself, discussed the CT and treatment plan with Mr P, or questioned why the groin lump had not been discussed with the patient.
  5. Finally, the experts were extremely negative about Mr P’s adding documentation 2 years after the appointment. They told the attorney that this would look particularly bad to a jury and would harm Mr P’s credibility.

The practice, supervising physician, and Mr P decided to settle the case out of court for an amount within their malpractice limits.

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Protecting Yourself

The experts identified many of the key issues in this case: poor communication with the patient, no referral given, no results provided to the patient, no oversight by the supervising physician, and a faulty computer system. But on the surface, the mistake that would look the worst to a judge or jury was Mr. P’s rash decision to amend the patient file 2 years later to include what he “thought” he had said at the time. Memory is faulty. It is extremely difficult to remember a conversation with a patient a week later, much less 2 years later. Notes must be taken contemporaneously, preferably at the point of care. Adding them to a patient’s record later can create doubt about the quality of patient care and the integrity of the provider.

Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, New York.