MD got dismissed due to this documentation
A repeat MRI was ordered by a family physician, along with a consultation with a neurosurgeon, for a 35-year-old male who presented with increasing neck and lower back pain.
The radiologist interpreted a worsening C6-7 disk herniation and instructed the radiology staff to contact the ordering physician with the interpretation. At the same time, the neurosurgeon contacted the radiology department and instructed the results of the MRI to be called in to the ordering family physician.
Radiology staff informed the ordering physician of the radiologist's interpretation and documented this contact. Three days after the MRI, the patient contacted the neurosurgeon requesting the results, and the practice contacted him two days later to set an appointment for five days later.
"The day before the appointment, the patient presented to the hospital with difficulty in moving his lower extremities," says Vanessa Mulnix, RN, MSN, CPHRM, CPHQ, senior risk management consultant at ProAssurance Cos. in Okemos, MI. The neurosurgeon performed emergency surgery, and the patient was discharged to rehab with a diagnosis of incomplete quadriplegia with improving gait dysfunction.
"Named in the suit were the neurosurgeon, the radiologist, and the hospital," says Mulnix. "The medical record as well as the documentation in the PACS [picture archiving and communication system] was reviewed." The following information was found:
- The documentation in PACS included the time the radiologist interpreted the MRI, the time he instructed staff to contact the ordering physician, and the time the radiology staff member contacted the ordering physician.
- The ordering physician documented the receipt of the MRI results, as well as the mailing and faxing of the results to the neurosurgeon.
- The ordering physician's patient medical record also included documentation of the fax number to which the report was sent.
- The faxed report, including the neurosurgeon's initials and the date the report was reviewed, was found in the patient's medical record at the neurosurgeon's office.
There was clearly documented evidence that the radiologist had timely communicated the need for communication of the MRI results to the referring physician, and there was timely documented communication of those results to the referring physician.
"These factors prompted dismissal of the radiologist from the suit after a fairly short period of time of eight months," says Mulnix. "This clear documentation also minimized the expense of defending the claim."
The ordering physician was not named in the litigation. The MRI result and response fell through the cracks, she says, and the documentation showed a path directly to the neurosurgeon. "This was a significant medical outcome for the patient, and one which could have had a large payout for the radiologist, were it not for the documentation," says Mulnix.