Legal Background

A few months later, Dr C was stunned when he was served with papers informing him that he was being sued by Mr F. The lawsuit claimed that the physician failed to properly manage the medication regimen and failed to monitor blood levels, resulting in the fall, subsequent injury, and poor recovery. He also claimed that the physician failed to warn him of the risk of bleeding due to warfarin.

Dr C felt hurt and outraged that his patient would turn on him like this, but he understood that the patient’s mental and emotional status had changed drastically since the head injury. Still, Dr C was determined to fight this case, and his defense attorney was supportive after looking at the detailed notes and documented calls to the patient which were never returned.

The case went to trial, and because of Dr C’s excellent documentation the jury agreed that he had properly educated the patient and that the patient’s injury was due to the patient’s own failure to go for his lab work and to schedule a follow-up appointment with his physician. Dr C was found not liable.

Protecting Yourself

Dr C did a good job of protecting himself by thoroughly documenting his instructions and his office’s attempts to reach the patient. This case, however, highlights the risks of miscommunication as a patient is transferred from a hospital setting to home. To minimize your risks (and increase your patient’s likelihood of success in following instructions), it’s important to consider the patient’s age, ability to drive, economic status, and history of failing to comply with instructions. Investigate if resources are available to overcome compliance challenges, and document those. Always document when you or your office makes follow-up calls or tries to intervene when patients are noncompliant.

It’s often a good idea to schedule a follow-up appointment before the patient leaves the hospital or your office, rather than ask a patient to call to schedule one. Remember that patients may have challenges that you are unaware of that make it difficult for them to get to appointments or to be compliant with their medication. Protect yourself with good documentation, but also try to protect your patients by providing education on community resources.