practice partner
Document
discussions about
side effects,
material risk
QA Tips
Y
ou decide to prescribe a different
drug to your patient. You discuss
with the patient the potential side
effects of taking this new prescription. The patient says that he appreciates the
risks, and agrees to try out the new medication.
An explanation of potential side effects and
material risks is an important discussion to
have because a patient’s consent is not valid
unless it is informed. So given the significance
of the discussion, why then do so many
physicians not document the fact of
this conversation in their clinical notes?
“The lack of
In reviewing the results from peer
documentation
assessments, the College’s Quality
Assurance (QA) Committee says it is
is a recurring
concerned by the significant number of
theme in peer
physicians who do not document the
assessments”
discussions about potential side effects
of medications in the medical record.
“The lack of documentation is a
recurring theme in peer assessments. We stress
in our decision letters to the physician that
although they may have discussed the potential risks and side effects with the patient, they
must also make a notation of such discussions.
Medical records are the only objective evidence
that discussions with patients did, in fact, take
place,” said Dr. Bill McCready, Co-chair of the
42
QA Committee, and a clinical nephrologist
from Thunder Bay.
Ensuring disclosure of any drug side effects
or material risks and then documenting the
disclosure will promote a patient’s trust in his
or her practitioner and reduce chances of a
successful patient complaint. In Canada, physicians have been taken to court by patients who
claimed they were not adequately informed of
side effects or material risks. And in a number
of these cases, the courts have sided with the
patients when the physicians were unable to
provide documentation that demonstrated the
patients were indeed informed of any potential
side effects of the therapy.
Clinical notes, said Dr. McCready, who
is also a Council member, must capture all
relevant information from a patient encounter. One of the most widely recommended
methods for documenting a patient encounter is the Subjective Objective Assessment
Plan (SOAP) format. It can also be easily
adapted to gather and document information obtained during other specific types of
encounters such as psychotherapy. While the
College recommends that physicians use the
SOAP format, other documentation methods
are acceptable as long as they capture all of
the elements of SOAP.
photo: istockphoto.com
Important tip for providing better
care to patients
Dialogue Issue 1, 2015
Issue1_15.indd 42
2015-03-19 11:18 AM