Legal Pearls: Ignoring Patient History Leads to Stroke
The patient was left a quadriplegic, having to spend the rest of his life in a nursing home, only able to communicate by blinking his eyes in response to questions. The patient had a grown daughter who consulted with a plaintiff’s attorney to see if the family had any legal recourse. The attorney, along with a medical expert, reviewed the patient’s medical file.
“Your father had a significant family history of stroke and myocardial infarctions,” exclaimed the attorney. “As soon as he came in with any signs that could have indicated stroke, he should have been sent to the hospital immediately!” The attorney agreed to take the case and filed a suit against the PCP.
When the physician found out he was being sued, he contacted the defense attorney provided by his malpractice insurance. After reviewing the medical records, the defense attorney asked the physician why he hadn’t taken his family history into account when treating him.
“That patient intake form is filled out of the first date that I see my patient,” said the physician. “I had been treating the patient for over 10 years—I don’t remember what the intake form says, and I guess I didn’t think to look at it again.”
The defense attorney suggested that they settle the case out of the court. Prior to trial, the parties negotiated a settlement of close to $3 million.
What's the "Take-Home"?
A patient’s medical history, including his or her family history, is an incredibly valuable document. It provides clues and insights and acts as a predictor for certain medical issues that run in families, such as stroke. It rightly should be an important component of a patient’s medical file, but if it is simply filed away and never looked at, it becomes worthless.
The physician should have suspected an evolving stroke when his patient reported double vision and lightheadedness. When the ENT specialist was unable to find a cause for the double vision, the physician should have immediately followed up. Had he treated the situation as the emergency that it was, the patient’s outcome might have been drastically altered.
Bottom Line—Your patient’s medical history, both personal and family, is an important clue to diagnosis and proper care. If you do not remember what your patient’s medical history is, review it! Taking a few moments to review a patient’s medical history can change the future for both your patient and yourself.
Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly the director of periodicals at the American Pharmacists Association, and editor of Pharmacy Times.