What documentation practices can help reduce allegations of a failure to diagnose breast cancer?
• Document a thorough breast examination in the history and physical examination; enter, in quotes, the patient’s breast complaints and what she says. • Use a diagram (or descriptive notes) to record the exact location of all lesions. • In the event that a patient’s breast care is being managed by another clinician, document the date of the patient’s last exam to ensure that subsequent exams are performed when appropriate. • During each visit, update the patient’s risk factor assessment and your recommendations for screening based on their current risk for developing breast cancer. • Consider using a problem list to highlight patients with a positive family history of breast cancer.
