Clinical Perspective

1. The patient did not receive colorectal cancer screening appropriate to her risk, based on age, presentation, or family history. Current guidelines from CRICO/RMF and national organizations recommend that everyone over the age of 50 receive some type of screening for colorectal cancer. Options for asymptomatic patients include colonoscopy every 10 years, annual fecal occult blood test (FOBT), flexible sigmoidoscopy every five years, barium enema every five years, and some combinations of those. Patients with symptoms, such as anemia, weight loss, or rectal bleeding should be referred to a specialist for a complete diagnostic workup. A single FOBT in the office alone does not qualify as a diagnostic workup nor adequate screening.
2. The physician did not know the patient’s sister died of colon cancer during their 20-year relationship, and a family history was not documented.
   Family history should be updated annually, as it is subject to change and may affect cancer and disease screening. The use of a questionnaire or prompt on an exam template can facilitate this process. Patients who refuse or are unable to complete the questionnaire should have an oral review of risk factors, including family history, and notes about the conversation should be put in the medical record.

Patient Perspective

1. The patient was not approached about a colon cancer screening test. The physician’s long term relationship with the patient and her history of missed appointments resulted in his making assumptions of her probable refusal for an FOBT series or a colonoscopy, although she had been willing to undergo cervical and breast cancer screening.
   A long term relationship between patient and physician is a usually positive attribute and patients often take very seriously the recommendations of a trusted doctor. Knowing a patient very well can lull a clinician into a lack of objectivity. Willingness to undergo other screening tests can suggest willingness to undergo colorectal cancer screening. Regardless of the patient/ physician relationship, all diagnostic and screening tests should be reviewed with the patient. Counseling, education and physician recommendations along with patient response including deferral or refusal should be documented in the medical record.

Risk Management Perspective

1. This was a non-compliant patient, who missed many appointments and requests to follow-up over 20 years.
   Patients who routinely fail to keep appointments are at risk for “loss to follow-up” The physician should be made aware of patients who fail to keep an appointment or repeatedly cancel appointments so that he/she can review the record and initiate appropriate outreach. All outreach efforts should be documented in the medical record.
2. The patient was not notified of the need for follow up testing for August 1999 blood work when she returned to the practice for episodic care in September. Lack of office practice processes to ensure continuity resulted in failure to follow up on an abnormal test result, even when the patient is in the office with another complaint.
   Recommendations for follow up should be prominently displayed in the medical record either on the problem list, or in the MD notes. Providers should routinely review documentation of previous visits before evaluating a patient with an episodic concern, and ongoing problems should be addressed with the patient at that time.

Legal Defense Perspective

1. Scant documentation with illegible components made it difficult to determine whether there was appropriate patient assessment and appropriate clinical rationales.
   Difficulty in deciphering notes and minimal documentation impedes the ability to defend a claim. Lack of documentation of a family history and evidence of discussion of colorectal screening pose obstacles for the defense. Standard templates including patient questionnaires and physical examination forms with prompts for age and gender appropriate health screening and counseling can encourage appropriate documentation.