 Forms and reports: the case for care
Of interest to physicians who fill out forms Although many physicians find forms and reports to be the bane of their existence, it is important to recognize they are part of patient care and must be given the same attention as diagnosis and treatment. The CMPA has been called on to assist members with threatened or actual litigation arising out of forms and reports. That assistance can be hampered when a form or report is inaccurate or incomplete. Even when the outcome is successful, the process can be difficult for physicians. Case: Inaccurate/misleading report In many provinces/territories, physicians are required to report patients with conditions that may impair their ability to drive. In one such jurisdiction, a physician was counselling a patient whose spouse was using drugs and alcohol. One day the spouse was at the office and the doctor observed signs of impairment. The spouse confirmed the recent use of chemicals, and the doctor advised that the spouse should not drive. This generated an angry outburst and the spouse left. The doctor subsequently wrote to the motor vehicle authority, stating that the spouse had been assessed and suffered from chemical dependency. The spouse's licence was suspended, whereupon a complaint against the physician was made to the regulatory authority (College). The spouse claimed to have only been at the doctor's office to pick up the patient, so there was no doctor-patient relationship with the spouse, no assessment had been done, and other physicians who had done assessments had not diagnosed chemical dependency. Outcome. After a careful review of the facts, the College found that the physician's letter was indeed inaccurate and misleading. Although the College expressed concern about driving while impaired, it noted that the law does not require a physician to report an impaired individual. The law in that jurisdiction requires a physician to report a person who has "attended upon the doctor for medical services and who, in the opinion of the doctor, suffers from a condition that may make it dangerous to operate a motor vehicle." The person had not attended for medical services, and the College believed there had not been an assessment sufficient to allow the physician to form an opinion, particularly one that was contrary to that of the spouse's doctors. The physician was required to attend the College to be cautioned in person. Case: Incomplete insurance form Some Canadians escape the rigours of winter by travelling to the United States; many of them apply for travel health insurance before leaving. A physician may be asked to certify a patient's health before insurance is granted. One patient was anxious to have the form filled out immediately and sent it by fax to the physician. The form required checking "yes" or "no" boxes in response to several questions. The physician checked only one box, and in the comments section indicated that the patient had suffered from hypertension and was currently on medication. During his stay in the U.S., the patient suffered a heart attack and on return to Canada submitted his expenses to the insurance company. The insurance company obtained the physician's records and found that the patient had suffered from heart disease in the preceding five years, which had not been disclosed by the doctor or the patient. The insurance company refused to reimburse the patient and the patient threatened to sue the doctor. Outcome. The lawyers for the patient and the physician were able to convince the insurance company that its agent had erred in accepting an incomplete form and the company did eventually make payment to the patient. Case: Undocumented discussion Another patient had a long history of heart disease. He was admitted to hospital with gastritis and elevated blood pressure. ECGs showed no changes. His antihypertensive medication was changed but no note of the change was made on the clinical record. The physician was not asked to fill out any forms for insurance. When the patient suffered complications in the U.S. and could not recover his substantial expenses from the insurance company, he threatened to sue the physician, alleging the doctor had not told him the purpose of the change in medication or about his pre-existing heart disease. Outcome. Regrettably, the doctor had not clearly documented his discussion with the patient but fortunately, records from a previous physician made it plain the patient had known about his condition and had not informed the insurance company. When this came to light, the patient did not follow through on his threat. The bottom line
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