News & Insights

Against Medical Advice: Noncompliant Patients & Documentation

February 07, 2017

By Ross McBryde, LAMMICO Claims Director

Against Medical Advice: Noncompliant Patients & Documentation

The best way to avoid a “he said/she said” claim is by utilizing good medical documentation of your interactions with patients – so don’t learn this lesson the hard way.

Scenario 1: A longtime male smoker visits your family practice office with a persistent cough. You verbally recommend a chest X-ray, but the patient doesn’t have insurance and advises that he cannot afford it. You prescribe antibiotics for the cough, but you document neither the recommendation for the X-ray nor the patient’s response to your recommendation. A year later, the patient is diagnosed with lung cancer by a specialist and subsequently dies of cancer. The patient’s widow recalls that you were his original family practitioner who treated him for a persistent cough and she subsequently claims negligence. Because you have no documentation of your verbal recommendation to a now-deceased patient, you find yourself in a malpractice lawsuit without adequate documentation to support your defense.

Scenario 2: A senior female patient arrives in the emergency room with complaints of chest pain. You evaluate the patient and due to her risk factors, you recommend that she be admitted for an evaluation with a cardiologist. However, the patient wants to go home and is discharged. You recommend that she follow up with a cardiologist but fail to document that she is being discharged against medical advice. The patient dies of a heart attack a few days later and her surviving children file a malpractice claim against you. Without medical documentation that the patient was discharged against your advice, this claim is more difficult to defend and may need to be settled.

As is the case with many malpractice claims, the absence of documentation to support these types of interactions with patients tend to become an issue of fact, and are often not resolved prior to trial. At trial, a judge or jury determines the credibility of your testimony compared to that of the plaintiff. With contemporaneous medical documentation, it is much easier to prove that you met the standard of care.

“Patient Tracking and Follow-Up” Practice Management Toolkit Available

LAMMICO makes it easier for healthcare providers and their support staff to streamline the patient tracking and follow-up process. Policyholders, their practice managers and their administrators are encouraged to register as a new user or log into our Member portal to access our Practice Management Member Resources. Here, special practice management toolkits are available for LAMMICO-insured administrators as an added benefit to our policyholders. To learn more, visit or register for Member access today at


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