Public Health Law Map - Beta 5 - Medical and Public Health Law Site

If, as frequently happens, the patient does not return for care, the physician could
be liable for any consequences that flow from the denial of care. This is also the
case when the patient is made to wait more than the medically acceptable time for a
follow-up appointment. If the obstetrician tells a patient to come back in three days
for a preoperative visit because it is time to put a stitch in her incompetent cervix,
the appointment clerk must not schedule her for an appointment in three weeks.
The obstetrician would be liable if the patient lost the fetus during this delay.
Physicians must ensure that a patient’s medical condition is considered when
appointments are being scheduled. They should always be consulted before a
patient is denied a timely appointment.
Triage is carried to an extreme in many MCOs. Patients cannot speak directly to a
physician, or even to the office staff, but must go through a triage nurse system.
These nurses, operating under some sort of protocols, call an ambulance for the
patient, direct the patient to go to the emergency room, send the patient to an MCO-
run urgent care center, or schedule the patient for an office visit. In some systems,
these nurses are pressured to keep patients out of the emergency room. The result
has been several deaths when patients with heart attacks or other emergency
conditions were sent to poorly staffed and poorly equipped urgent care centers. As
plaintiffs’ attorneys litigate these cases, they will seek to tie the nurses back to both
the MCO that employed them and to the physician who approved their protocols
and carried out the oversight of their actions.
d) Evaluation of Medical Tests
Physicians sometimes implicitly delegate the evaluation of medical test results to
their filing clerk. This happens when the office charting system is not set up to
ensure that every test result is reported to the physician. From both a legal and a
medical standpoint, a test should not have been ordered if the results do not warrant
evaluation. Deciding that a report is normal for a patient is a medical judgment. A
physician may reasonably delegate many of these evaluations to laboratory or
nursing staff—the gynecologist does not need to see every normal Pap smear report
that comes back—but there should be a formal system for checking in the reports,
and it should be explicit about what can be filed and what must be evaluated by the
physician. If a laboratory report did not come back at all, it needs to be located or
the test repeated. Physicians do not need to review every piece of paper that comes
to the office, but there must be specific written orders or protocols for handling
reports and for finding lost reports. The receptionist must have a tracking system
that identifies and locates patients who miss appointments or fail to make return
appointments the physician has recommended. For example, if a report comes back
with a notation that the patient has a spot on a lung X ray, some action should be
taken. Nurses in the office might have a protocol that allows them to arrange
treatment and a follow-up visit, or the secretary might have instructions to pull the
chart and leave it with the report on the physician’s desk.
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