1. Nicholson, Sheila K. PT, Esq., MBA

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When a patient's condition changes, you as a physical therapist (PT) must quickly consider when, how, and what to communicate to the physician. As you do, remember that these questions have not only clinical implications, but also legal implications.


Message sent-and received

In medical malpractice lawsuits brought against PTs, one question tends to recur: Was an important change in the patient's condition communicated to the physician in a timely and appropriate manner? You may communicate clinical information by speaking directly with a physician or by using a telephone, fax, progress notes, or one of several electronic methods. But to protect yourself, you must make sure your communications are sufficiently documented.


If a lawsuit is filed and the lack of timely or appropriate notification of the patient's condition is an issue, discovery-the compulsory disclosure of facts-may be used to determine when, how, and what you communicated to the physician. Unfortunately, many cases make it to the discovery phase months or even years after the incident, and the likelihood that anyone will remember a specific communication is slim to none. Thus, the legal defense team must evaluate evidence (documentation) to establish that communication with the physician was appropriate and timely.


Such communication requires a speaker of information and a listener who receives it. With copies of faxes, progress notes, or electronic messages, the defense team can usually establish that the speaker sent the information. Typically, the problem is whether the intended listener received the information.


Plaintiffs often argue that if the intended listener had received the information, he or she would have taken some action. Because the record lacks evidence showing that the action took place, the argument goes, the listener obviously didn't receive the information. During deposition, other healthcare providers may testify that if they had the information in question, they would have taken a particular action. That's why the defense team will look for ways to establish that the appropriate listener received the information.


Establishing evidence

Here are some protective suggestions for establishing that the appropriate listener received the information at issue:


* Face-to-face or telephone communication. In the physical therapy progress notes, document the date and time, the person you spoke to, the substance of your communication, and the physician's stated plan of action. To go a step further, write a letter to the physician that recapitulates the communication and keep a copy in the patient's medical record. You can also copy the patient on the correspondence.


* Faxes. Print the fax confirmation sheet that says "Transmission OK." Then call to verify that the intended recipient received the information. Document the date, time, and the name of the person who confirmed that the intended recipient received the faxed information.


* Progress notes. On progress notes sent with the patient, provide a place for the physician to acknowledge receipt. Request that the progress notes be faxed or returned at the next appointment so you can make them part of the patient's medical record. If nothing is returned, write a letter to the physician with another copy of the progress notes. In the letter, state that because no information was returned, your understanding is that no changes in physical therapy should be incorporated into the treatment plan.


* Electronic communications. You can send an e-mail message requesting a return receipt on delivery, a notification that the message was read, and a notification that the message was deleted. However, you have no way of knowing who received, read, or deleted your e-mail, so you may want to call the physician and confirm receipt of the information, including the documentation discussed.



Legally speaking, proving that you sent important patient information to a physician isn't enough. A physician can simply say that he or she never received it. To protect yourself from legal harm, you need to establish evidence that the physician actually received the clinical information you sent. That means creating a record of what you communicated, when you communicated it, and who received it.