800.232.7645, The Dentists Insurance Company Has 14 years experience. The boxes of charts were a visible reminder to him, to the staff and to administration of the problem. These include the right: To courtesy, respect, dignity, and timely, responsive attention to his or her needs. 3. Available at www.ama-assn.org/ama/pub/category9575.html. Under federal and state regulations, a physician is legally prohibited from discussing a patient's medical history with anyone unless the patient permits it. Together, we champion better oral health care for all Californians. A key part of documenting the refusal is to explain your assessment and potential adverse impacts on the patient's condition for refusing the recommended care. Patient Non-Compliance A Powerful Legal Defense By: Becky Summey-Lowman, LD, CPHRM This article is reprinted with permission from Healthcare Risk Manager, a publication of MAG Mutual Insurance Company's Risk Management/Patient Safety Department, Vol. question: are birth control pills required to have been ordered by a doctor in the USA? "Document when patients admit to non-compliance, and document discussions or instructions you give to patients who are, or who are likely to be, non-compliant," says Scibilia. American Academy of Pediatrics. The day after his discharge, the patient suffered an MI and died. Informed refusal. Note examples of pertinent information include the patients current dental complaint, current oral condition by examination and radiograph findings. A psychiatrist may be insecure about revealing poor record-keeping habits or, more subtly, may feel discomfort with the notion that reading the chart allows the patient to glimpse into the psychiatrist's mind. Do's and don'ts of nursing documentation | NSO is a question Ashley Watkins Umbach, JD, senior risk management consultant at ProAssurance Companies in Birmingham, AL, is occasionally asked, and the answer is always the same: "It's because the doctor just didn't have any documentation to rely on," she says. Formatting records in this fashion not only helps in the defense of a dentists treatment but also makes for a more thorough record upon which to evaluate a patients condition over time. Potential pitfalls: Risk management for the EMR. The general standard of disclosure has evolved to what an ordinary, reasonable patient would wish to know. Any resource shared within the permissions granted here may not be altered in any way, and should retain all copyright information and logos.