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Tips to avoid trouble . . .
An article for physicians by physicians
Originally published December 2007
IL0740-3-E

Of interest to all physicians

This is the second in a series of articles based on observations by Medical Officers at the CMPA who communicate with members on a daily basis. The content is simple yet the issues arising from each may be complex. Read on to discover how you might reduce your risk of medico-legal difficulties.

These tips are not intended as guidelines nor do they represent any standard of care.

Tip # 4

Document your care

An accurate, objective and legible note in the medical record made at the time of the patient encounter is likely to improve your patient’s care and be of assistance if your care is ever questioned. Also:

• It will be easier for others to interpret the record if only generally recognized abbreviations are used.
• Any subsequent additions or changes should be dated and signed at the time you make them to avoid undermining the credibility of any changes.

Your regulatory authority (College) has guidelines and/or policies available for appropriate record-keeping.

Tip # 5

Follow up as appropriate on investigations

Failure to follow up on investigations may result in harm to your patient and may also lead to medico-legal difficulties. In circumstances where a legal action results, it is often difficult to obtain expert support for the care provided. The courts have repeatedly determined that the ordering physician is responsible for the timely and appropriate follow up of the results of investigations.

This remains a difficult and challenging task for most physicians, despite improvements in reporting systems.

It is also prudent to document the efforts made to advise your patients of important results.

Tip # 6

Prescribe with care

Problems related to the prescription of medications continue to be cause for concern for both patients and health-care professionals.When prescribing medications, consider the following:

• Are you familiar with the medication?
• Are you familiar with your patient’s other medications and potential interactions?
• Do you know the correct dosage and appropriate route of administration for this medication in the circumstances of this particular patient?
• Have you explained the risks, benefits, side effects and potential alternatives (obtained informed consent) to your patient?
• Have you instructed your patient on what symptoms might indicate difficulties and how and when to seek additional medical care should they occur?
• The names of many medications sound alike and may look alike when written. Have you prescribed the correct medication? Are your verbal orders clear and your prescriptions legible?

Timely and effective communications with the dispensing pharmacist may also assist in avoiding medication problems for your patient.