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Non-compliant patients require more than just documentation
e-Reports, Feb. 4, 2013
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ProAssurance offers risk management recommendations to help you with equipment, resources and discharge planning. Untitled document

Q. What tips can you offer regarding non-compliant patients?

A. It’s a common refrain: document, document, document. During the informed refusal discussions you have with patients, some additional suggestions offered here may reduce your risk because what you may not know is that documentation of a discussion may not be enough.

Risk management experts say that when non-compliance results in illness or injury, patients may complain, “The doctor didn’t tell me how important it was to get the test.” Juries may find sympathy with such a claim.

When discussing a patient’s course of treatment, risk management experts advise thoroughly explaining the diagnosis, recommended treatment, risks and benefits, and any alternatives to recommended treatment – along with the risks of non-compliance. Document the discussion. Also, note that you answered questions, the patient accepted the risks and agreed to proceed with the treatment or procedure.

If a patient decides to refuse treatment, discuss potential consequences of that refusal. Document that you advised the patient of the risks of refusing treatment and the patient’s reasons for refusing. Consider having the patient sign an informed refusal form indicating you explained the treatment/procedure, discussed the risks of no treatment, and the patient elected to refuse. Give the patient a copy of that form.

When patients refuse treatment, encourage them to obtain a second opinion and document the discussion, making a notation on the refusal form. Advise patients to contact you if they change their minds and want to proceed with a recommended course of treatment.

It’s also a good idea to document a patient’s failure to follow advice, take medication, obtain requested diagnostic studies or other actions a patient fails to take that may contribute to an injury or delay resolution of a medical problem.

These efforts may go a long way toward demonstrating to a jury that the importance of recommended treatment was discussed with the patient.

Physicians insured by ProAssurance may contact our Risk Management department for prompt answers to liability questions by calling (800) 292-1036 or via e-mail.

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