Strategies to Mitigate Risk Related to Documentation, Communication & Follow-up

MLMIC sees a significant number of claims that occur due to lack of documentation and communication, as well as various issues regarding follow-up. To mitigate these potential threats, universal risk management strategies can, and should, be employed by all healthcare providers. Through analysis of case reviews and data on closed medical malpractice claims, MLMIC has identified key areas with opportunity for improvement and strategies to mitigate potential risks in future patient encounters.


Physicians communicate on many levels: with patients, families, pharmacists, therapists, other healthcare providers and insurance agents. At each level of interaction, effective communication is essential to developing and executing the best plan possible for optimum patient outcomes.

Below are strategies when communicating with the following:

Patients and family members

  • Acknowledge that the perception of physician communication skills may impact the potential for allegations of malpractice.
  • Promote open communication with patients to enhance their ability to reach an accurate diagnosis and develop an appropriate plan of care.

Physicians and other healthcare providers

  • Recognize poor communication among providers can result in poor care coordination and increased liability risks for all involved parties.
  • Develop systems to address and document calls from other providers.
  • When consulting with another specialist, physicians must do the following:
    • Define the roles and responsibilities of all involved parties, including the patient.
    • Delineate the steps to take when a patient fails to keep a follow-up appointment.
    • Implement a system for providing office notes and updates on care.
    • Coordinate provider responsibilities for treatment and the follow-up of tests.
    • Manage the transition of care back to the PCP when the consulting physician’s treatment plan is complete.
  • Provide prescription clarification from patients and pharmacists:
    • E-prescribing, while dramatically reducing legibility issues, does generate telephone calls to address parts of the prescribing process, such as dosage, interactions or availability issues.

Advanced practice providers:

  • Encourage clear and concise communication among healthcare professionals to promote safe and more effective patient care.
    • Establish parameters for supervision, including but not limited to patient care oversight, coordination of care and availability of a supervising physician for consultation.


The medical record is a legal document and the primary means of communication among members of the healthcare team. The information contained should tell the patient’s story, capture the care that was rendered and reflect the patient’s response to treatment. Failure to maintain proper medical record documentation can be seen as both malpractice and professional misconduct.

The following elements should be considered when documenting patient care:

Plan of care:

  • Comprise a descriptive, clear and concise treatment plan for the patient, inclusive of the critical-thinking process used to determine the current direction of care.

Care developed:

  • Confirm there is a detailed written account of the care provided to the patient, including his/her responses and treatment outcomes.


  • Incorporate notes regarding the patient, including but not limited to ordered tests and results, consultations, all telephone calls, notes from covering physicians, changes in the patient’s condition and the provided family history.

Documentation at the time of care will always be more accurate and reliable than any recollection of events. In litigation, the medical record will be reviewed by both the plaintiff and defense counsel, as well as experts, to determine the merits of a case and prove or disprove liability. Clear, timely and complete documentation can stop a plaintiff’s attorney from proceeding with a claim or a suit.


Follow-up is an integral part of healthcare. Medical appointments may be missed or forgotten, tests may not be completed, or results may be lost, overlooked or not received. Any one of these acts can contribute to a potential delay in diagnosis or misdiagnosis and subsequent liability exposure. The following steps should be taken to ensure a seamless patient care plan:

  • Educate patients/families on the importance of complying with the plan of care.
  • Use a system to track tests and consultations.
  • Document all measures taken to contact the patient.
  • Determine if the physician/patient relationship can continue if/when a plan of care is not followed/disrupted.

For tests and consultations:

  • Document and track the dates when:
    • the test and/or referral was performed;
    • the results and/or recommendations were received and reviewed; and
    • the discussion of study results with the patient and any advice given.

For missed appointments:

  • Advise the provider of all missed appointments.
  • Adjust the care plan as needed.
  • Explore the reasons for the missed appointment.
  • Re-educate the patient on the rationale for keeping appointments.

Policyholders are encouraged to review the complete MLMIC ANALYTICS Million Dollar Claims Report.

Additionally, MLMIC offers a number of risk management tips to help physicians and healthcare organizations improve patient care and, ultimately, reduce the number and severity of claims: