Requesting and reviewing a summary from the prior physician that provides key points may save time.  However, this standard process may not provide safe, quality patient care or insulate from liability.  Consider those circumstances in which the prior physician may have overlooked and not included key information in the summary.  Only through review of the prior medical record and current assessment of the patient would you be aware of significant information that must be addressed with the patient in the future.

The added benefit of implementing the standard process of medical record review prior to the patient visit is physician and patient satisfaction – you are not rushed or frustrated during the office visit and the patient has your full attention.

Liability Issues

Although it is general knowledge within the medical community that poor patient outcomes may or may not lead to liability, awareness of factors in failure to diagnose or treat related claims has raised physician concern:

• The greater the volume of the medical record the greater the risk that important clinical information could be missed.
• The possibility of assuming liability for acts of the prior treating physician.

Reviewing the 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. 

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.”

It is also important to accurately and objectively document a new patient's condition at the time you assume care. This, combined with a thorough review of prior care treatment records, should "keep the record straight" regarding the care you provided in case the prior care is problematic.

Summary

Although time consuming, to promote safe, quality continuum of care and avoid allegations of failure to diagnose, treat or follow-up the physician assuming care of the patient should obtain the medical record from the prior physician and review it before the patient’s first visit. 

This article is intended to make healthcare professionals aware of new patient risks and to serve as a general guideline in developing policies and procedures. This article is not intended as legal advice. Readers should consult professional counsel familiar with federal and state laws for guidance with specific legal, clinical or ethical questions.