Assuming care of a new patient from departing or retiring physicians within a group practice or within the community presents unique responsibilities to physicians. Physicians who do not review prior medical records, but instead rely on the patient’s account of their clinical history run the risk of missing pertinent clinical information that may lead to poor patient outcomes and potential liability.
Some patients may be poor clinical historians and/or may not completely understand significant information or instructions shared with them by prior physicians. To promote safe, quality continuity of care and avoid allegations of failure to diagnose or failure to follow-up, the new physician assuming care of the patient should obtain the medical record from the prior physician and review it before the patient’s first visit.
Requesting and reviewing a summary from the prior physician may not provide safe, quality patient care or insulate from liability. Consider those circumstances in which the prior physician notes a patient complaint but did not follow through. The information may not be included in the physician’s summary. Only through review of the prior medical record and current assessment of the patient would the new physician be aware of significant information that must be addressed with the patient in the future.
Once the physician reviews the medical record an entry in the medical record noting pertinent history and current healthcare plans and needs should be made. An example of such documentation includes: “4/17/07. Assuming care from Dr. Smith who retired. Chart reviewed; continue medical management of diabetes; appointment scheduled in one month; order labs, consider nephrology consult if kidney function continued to decline.”
Reviewing the prior medical record before the patient’s first visit will save valuable time during the actual visit. This process may avoid the need to skim through the record during the visit thereby averting the risk of missing important clinical information.