What documentation practices can help reduce allegations of a failure to diagnose colorectal cancer?
Document a thorough history and physical examination; enter—in quotes—the patient’s complaints and what you understand was being reported. • Based on history and physical examinations, make appropriate screening recommendations and mode of screening to be utilized (as agreed upon with the patient). • If symptoms present, recommendations should be made that are in compliance with the algorithm—or document any advice rendered that deviates from the recommendations, and your select clinical rationale. • Use descriptive notes to record the exact presentation of all symptoms. • In the event that a patient’s colorectal cancer screening is being managed by another clinician, document the date and mode of the patient’s last screening effort. • During each visit, update the patient’s risk factor assessment and your recommendations for screening based on his or her current risk profile for developing colorectal cancer. • Consider using a problem list to highlight patients with a positive family/
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