Most physicians who treat close friends or relatives don’t keep detailed charts, if there are charts at all. No matter the patient, accurate and complete records must be kept- a lesson the physician in the following example learned the hard way.
The physician in this case, a dermatologist, was sued for professional negligence by a former friend. The dermatologist had called in an antibiotic for her twenty-something year old friend, that was experiencing a UTI, and prescribed Cipro. Her friend told her that she had taken it in the past for this and it worked. Her friend also had an erythematous area on her right hand with no purulence, but with some localized elevation of skin temperature. This was confirmed after an in-person visit the next morning. The physician verbally gave instructions as to how to take the Cipro and that she was prescribing it for the apparently infected area of her right hand, not the UTI. She was emphatic that her friend must see her primary care provider, Gynecologist, or urologist for the UTI. She emphasized that as a dermatologist, UTIs were not in her normal scope of practice, and her friend should get the prescription of an appropriate antibiotic.
The apparently infected area of her hand cleared up in 3 days. The dermatologist’s “friend” never went to a physician for her UTI. In fact, it was not a UTI, it was a venereal disease that was not effectively treated with Cipro. As a result, the patient became unable to conceive. None of this was ever written in any chart. All the physician’s defense attorney had was a prescription bottle saved by the plaintiff that stated on it: “Cipro 500 mg 1 tab po qd for infected area.” There was also no insurance form, as the dermatologist treated her as a favor to a friend. The gist of the litigation was that the dermatologist practiced negligently as concerning the UTI. The dermatologist had little with which to defend herself. Fortunately, there was a prior infection of the hand that was treated successfully, the same way, a year or so prior to the matter at issue.
However, it did not end there. The “friend”, after she was unsuccessful with her malpractice case, reported the dermatologist to the Medical Board. The Board examined the patient’s medical records and found them to be woefully insufficient for the date at issue. This led to the dermatologist license sanctioned for inadequate/absent medical records. The moral of this story is to keep complete and adequate records on every patient, including those who you “do a favor for.” Please have your records state clearly the condition you are treating, and to who you are referring, and the reasons why.