The Importance of Proper Consultation Notes

JACKSONVILLE—At issue is failure of the consultation process. The solution: in all hospitals and physicians’ offices, the consultation process should be conducted in line with professional standards and expectations.

Timothy R. Bone, president of Jacksonville-based MedMal Direct Insurance, outlined a simple review procedure:

• Obtain the assistance of the Medical Records Department in your hospital or clinic to identify 50 charts of patients recently discharged from the hospital who had consultations performed during their hospitalization.
• Review each chart to assess the following factors:

o       Is the mechanism for obtaining the consultation recorded? That is, how was the consult requested: telephone call to the consultant, written order in the chart, verbal request to a nurse, or completion of a formal consultation form?

o       Does documentation exist pertaining to the specific questions posed to the consultant?

o       Is there documentation of the time lapse between the request for the consultation and its completion by the consultant? If so, does the time lapse seem reasonable?

o       Were the recommendations of the consultant addressed by the attending physician? That is, were any resulting orders initiated, was the patient transferred to another service, et cetera?

o       On a scale of 1 (poor) to 10 (outstanding), was the specific consultative process completed in a proper professional manner?

• After the review of 50 consultations and the assignment of an appropriate rating to each, add the numbers to achieve a total amount; divide that amount by 50 to obtain the average numerical rating for initiating the consultation process in your hospital or clinic.

Recommended Actions

“If all seems to be in order, notify the Medical Executive Committee at the next staff meeting,” said Bone. “If problems exist, notify the Medical Executive Committee and propose a solution in cooperation with your hospital or clinic administrator, implement it, and re-audit the issue after approximately three months, reporting to the Medical Executive Committee about that activity.”

Proper consultation is the backbone of medical practice, Bone emphasized.

“On a number of occasions, associated disputes entered in the medical record have spoken for themselves’ in finalizing the jury’s assessment of malpractice,” he said. “It’s appropriate to record differences of opinions, but it’s imperative to do so in such a fashion as not to add fuel to the fire.”

If a hospital, clinic or a physicians’ practice can examine and significantly change the way physicians and staff communicate and interact with each other and with patients, the tendency of patients to file malpractice claims may be reduced, Bone added. 

“Even though insurance (risk transfer) and tort reform (minimizing severity through legislation) are essential approaches to address society’s pervasive medical malpractice problem, risk management remains the best hope for controlling the frequency and severity of medical malpractice claims,” Bone said. “When approached objectively using the scientific method, risk management methodologies encourage those concerned with the problem of malpractice to address it with the goal of prevention and with the resolve necessary to effect meaningful and lasting change. These reviews take some effort, yet have shown, over time, to achieve the stated goal: mitigation of the risk that leads to medical malpractice lawsuits.” 

Editor’s Note: This article marks the fourth in a risk management series with Timothy R. Bone, president of Jacksonville-based MedMal Direct Insurance. Florida Medical News papers will address some of the most common non-clinical problems by objectively approaching each issue and its resolution via the scientific method. This process includes providing an “outcome goal” or objective, and then offering a relatively simple approach to data-gathering via chart review, observations, or simple surveys.

The series flows from the following known fact: as much as 80 percent of all medical malpractice lawsuits are generated from non-clinical issues in the practice of medicine.

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