Analog, Digital Documentation to Safeguard Patients, Practices

Malpractice claims against dermatologists are lesson common than those filed against physicians in other specialties, said Susan Kendig, WHNP, JD, a women’s health integration specialist at SSM Health-St. Mary’s Hospital in St. Louis, Missouri, and director of policy for the National Association of Nurse Practitioners in Women’s Health in Washington, DC.¹ While that is good news for dermatology practices and providers, it does not diminish the importance of strategies that increase patients’ safety while limiting practice and provider liability.

In her presentation at the 3rd annual Society of Dermatology Nurse Practitioners Symposium,² Kendig pointed out that many of the errors that, tragically, did lead to patient mortality could likely have been prevented simply by the better utilization of tools every practice has at its disposal to track patient history and ensure follow up care where needed.

Building Better Records

Clinical photographs are only one key component in a patient’s electronic medical records (EMR), but they demand a rigorous set of evidence-based practices. “These images serve a medical and legal purpose,” Kendig said.

To that end, management of these files goes beyond the basics of using a high-quality camera, confining photos to the lesion in question, labeling said lesion with an arrow or mark, and protecting the patient’s identity. “Photos should show close-ups of the lesions and images taken at a distance for context,” Kendig said.

Make sure the lesion is documented in multiple ways, she added.

Photograph it next to a ruler for measurements and make sure the documentation matches the photos.

Always identify images by written-note observations and be as thorough as possible. “If there is inflammation around a lesion, note that,” Kendig said, adding that such information is helpful for the pathologist.

Integrate images into a patients’ EMR and keep them there. Kendig also noted that practices should ensure all images are deleted from the device on which they were taken and from any other storage locations except the EMR.

Do not purge records without careful consideration, as preserving a thorough patient history can help prevent critical information—such as growth in a suspicious lesion—from falling through the cracks if patients change providers or are under the care of multiple providers.

Improving Follow-Ups with Patients and Colleagues

Creating the treatment regime and protecting patients’ records are just 2 aspects of patient safety. Physicians also should focus on follow-up to deliver optimized outcomes. “It is never a case of, ‘We tried 3 times [to reach the patient] and that was enough,’” said Kendig, of ensuring patients act on appointments and referrals. If patients are not coming back for follow-up, a broader range of outreach—from phone to certified letters, so that the practice can track whether reminders reached the patient—can help practices get them back in the door of the same practice for necessary procedures or monitoring. If the next appointment is with a different provider, she advised that patients be asked if they have been seen for the condition before and for a health history, even if they were previously seen by another provider in the same practice.

While some larger medical systems have EMRs in place for closed-loop referrals—an approach that Kendig said works fairly well for tracking whether patients show up to appointments—she cautioned even these proactive measures are not infallible. “In some EMRs, the alert to follow up on a referral disappears if clicked on instead of making the provider actually follow up.” For practices without this kind of tracking, Kendig suggested setting up follow-up appointments with the original provider after they have seen the provider they were referred to.

If the dermatology practice is the one to whom patients are being referred, Kendig advised that they impress the urgency of that referral on the referring provider, citing that melanoma is second only to breast cancer among pathology-related malpractice claims. The provider also needs to review the patient history, including any previous pathology reports, to scan for potential issues.

Reducing Liability Beyond the Exam Room

Having covered best practices for preventing poor outcomes, Kendig touched on patient consent for image release—an aspect of practice that, while not typically connected to health outcomes, has become more complex as imagery is distributed in more varied ways.

A catchall consent form is inadequate as legal protection. Patients need to sign off on the specific intended use of images, whether that is educational or promotional, and the language on consent forms must accurately reflect that. “Remember that while images are essentially owned by the practice, it is the patient who controls the information and how it is used—and for images in EMR, HIPAA rules apply,” Kendig said.

References:

1. Kornmehl H, Singh S, Adler BL, Wolf AE, Bochner DA, Armstrong AW. Characteristics of Medical Liability Claims Against Dermatologists From 1991 Through 2015. JAMA Dermatol. 2018 Feb 1;154(2):160-166. doi: 10.1001/jamadermatol.2017.3713. PMID: 29214284; PMCID: PMC5839273.
2. Kendig S. Legal Considerations for Dermatology NPs. Presented at: The Society of Dermatology Nurse Practitioners Annual Symposium; April 22-23, 2022; Nashville, TN.