Complete medical records are vital in cases of potential malpractice



Fleming T. Failure to diagnose in eye care. Presented at: Optometry’s Meeting; Denver, Colorado; June 24-26, 2021.

Fleming reports no relevant financial disclosures.

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DENVER – Carefully handle patients who phone your office with complaints, as this situation could make you and your practice vulnerable to a malpractice claim, Theresa Fleming, OD, JD, said in her presentation here at Optometry’s Meeting.

“The most difficult situation is when someone calls in and says they have pain and deteriorating vision,” Fleming said. “That’s the scary one. Will you be writing notes on every single person that calls your office? They may not be a patient of yours, and you have no file on them.

“Is your staff trained to appropriately respond to an emergency phone call?” Fleming continued. “What does your phone answering message say?”

Fleming said, “Records are vital. Make sure your notes are clear, concise and complete.”

She shared an example of an actual malpractice case based on “failure to diagnose.”

A patient had cataract surgery and then six follow-up visits. She called the practice after the sixth visit to say she had pain and deteriorating vision.

“Six visits is a lot,” Fleming said. “I’ve never heard of six follow-up visits. It made me think that this was a high-risk patient.

“When the patient called, the doctor was unable to see or speak to her because he was at another office that day,” she continued. “The day after the phone call, she came into the office, and she was diagnosed with a retinal detachment.

“This shows a time-sensitive standard of care,” Fleming added.

“Is your high-risk patient warned of the signs and symptoms of retinal detachment?” she asked. “Is the high-risk patient told where to go for care [if you are unable to see them]?”

If the doctor knew the patient was high risk, the phone call should have been returned the next day. Perhaps the staff should have advised the patient to seek care elsewhere, Fleming said.

“What were the patient’s complaints during that unanswered phone call?” she asked. “Shouldn’t every visit end with a recommendation of when to return?”

Clinicians can consult a number of resources to decide on what constitutes standard of care, she said, including: the American Optometric Association’s Clinical Practice Guidelines, the American Academy of Ophthalmology’s Preferred Practice Guidelines, The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, The Wills Eye Manual, peer-reviewed journals and textbooks, and case and state law standards.


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Elena Johaness

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