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Patient-centered approach still requires documentation


A patient-centered approach to medical care holds that the patient holds responsibility for his or her own care.

The patient may make an informed refusal, and you must honor the wishes of the capacitated patient who refuses treatment. Document this information in your progress notes, and have the patient sign a refusal-of-consent form.

Patients also may refuse medications when they are not absolutely needed and because of concerns about possible side effects.


The principle of comparative negligence allows liability to be distributed between the plaintiff/patient and the defendant/doctor in a malpractice lawsuit. It also allows for a plaintiff's recovery to be reduced proportionate to the plaintiff's degree of fault in causing the damage.

If you are sued, you can make a counter-claim for comparative negligence on the argument that the patient understood the diagnosis and the recommended course of treatment, was not adherent, and worsened his or her condition. Your documentation will provide evidence of the degree of patient responsibility.

When you discuss consent, diagnosis, treatment, follow-up, and other matters, make sure you document having done so. Have the patient sign your note, or use a separate form such as the one at http://memag.com/consentform. The main value of such documentation is to cause the patient to think, but it also may support your defense in the event of a lawsuit for lack of informed consent, failure to follow up, or comparative negligence.

The author is health law attorney in Mt. Kisco, New York, and a Medical Economics editorial consultant. Malpractice Consult deals with questions on common professional liability issues. Unfortunately, we cannot offer specific legal advice. If you have a general question or a topic you would like to see covered here, please send it to medec@advanstar.com

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