The Critical Importance of Acquiring Proper Medical Clearance

Gallagher Healthcare :: Industry Insights

By Gallagher Healthcare | 9/23/2022

The Critical Importance of Acquiring Proper Medical Clearance

For better or worse, not all elective surgeries need medical clearance. The medical clearance process isn't always worth the extra work for healthy adults. Medical clearance is usually reserved for the very young, older adults and individuals with comorbid conditions.

When medical clearance for surgery is needed, proper attention to process is paramount. Insufficient medical clearance increases malpractice lawsuit risks and endangers patient health. Continue with this article to learn more about the most common causes of malpractice claims and what you can do to prevent them.

Malpractice Claims Can Often Hinge on Preoperative Evaluations

Although the charged issue in malpractice claims usually occurs during or after surgery, those issues are most often rooted in preoperative oversights. The crux of these preoperative issues surrounds miscommunication at one or more levels. The most critical level is when doctors give medical clearance despite incomplete or outdated patient records.

Medical clearance is a doctor's authorization that a patient can undergo surgery. Before the evaluating doctor gives medical clearance, they assess the risk that the patient's medical issues pose for surgical complications. If risks are high enough, the evaluating doctor may deny medical clearance or suggest an alternative treatment route.

Physicians view cardiovascular, respiratory, blood clotting or coagulation conditions as surgical comorbidities. Patients with such conditions are the most common subject of malpractice lawsuits. That said, physicians also know that any condition, be it a cold or heart disease, increases surgery risks.

For these reasons, thorough clearance exams are essential for elective surgeries with comorbidities. If a patient has had adverse anesthetic reactions or suffers from excessive bleeding, it should be explicit in the clearance exam. If that information isn't clear, the evaluating doctor should seek further clarification before giving preoperative clearance. Insufficient medical clearance can lead to severe consequences for patients. It can also spell potential lawsuits for medical providers.(/p>)

Still, preoperative miscommunication is a significant cause of malpractice claims. Lack of communication during the preoperative process can occur due to several reasons. For instance:

Physicians may consider a certain procedure low-risk: As a result, they may conduct surface-level evaluations without clarifying or reviewing the patient's answers.
Others may depend on a previous specialist's evaluation: Trusting that the previous specialist conducted a thorough review presupposes that they made no mistakes evaluating the patient's condition.
Patients often skim online questionnaires: Many patients answer online questionnaires without much thought. Without reviewing and clarifying patient answers, critical information influencing the patient's eligibility for surgical clearance may get lost in translation.
Patients may feel pressured by time constraints to collect records: As patients are responsible for collecting their medical records, they may feel pressured by time constraints to have their surgery as scheduled. Such pressure may result in incomplete or out-of-date records that leave out pertinent information.

In this way, mistakes made in previous evaluations or operations may get glossed over. Like a game of telephone, a weak point of insufficient assessment can be the first seed of miscommunication. This seed can lead to misguided clearance, surgery complications and a potential lawsuit.

Preoperative testing algorithms and electronic health records have made physical examinations less essential. Still, they remain an excellent safeguard against miscommunication. Even if a preoperative test doesn't prevent a lawsuit, it can help dismiss you from one.

How to Avoid Malpractice Claims Based on Insufficient Medical Clearance

There are several ways to avoid the consequences of miscommunication during the preoperative evaluation period. First, physicians and nurses must view medical evaluations as actual patient care rather than a mere routine process. It's also crucial to establish a robust and straightforward protocol for obtaining medical clearances. Such protocols should involve clear communication and extensive documentation. They should also emphasize the importance of explicit written clearance.

Communicate Clearly

Clear communication is essential for any workplace to function efficiently and avoid hazards. It is especially important in high-risk occupations, like medical and surgical care. Here are some tips for clear communication to ensure proper medical clearance is given:

Let patients know clearance expectations immediately after scheduling their surgery.
Avoid placing undue pressure on patients to obtain records. Give them enough time to collect records and speak with specialists.
Reach out to the patient's previous specialists if you receive incomplete or outdated forms.
Have patients sign releases allowing you to obtain the records whenever possible.
Don't rely solely on online questionnaires — patients may skim through them with vague answers. Online questionnaires provide preliminary data that requires validation at several levels. Follow up on questionnaires to fill any gaps and clear up any inconsistencies.
Listen intently to patients' answers and probe deeper if those answers are insufficient.
Train nurses and physician's assistants to listen to patient responses with an ear tuned to possible complications to ensure optimal quality with your preop tests.

Document Everything

With documentation, the surgeon is responsible for providing the evaluating doctor with current information on:

The patient's condition.
The type and anticipated length of the surgery.
The type of anesthesia they expect the patient to receive.
How long the patient may be immobile after the procedure.
Details about the patient's rehabilitation plan.
The expected recovery period.

As the surgeon documents this information, they should take special care to thoroughly and correctly fill out each patient's official medical record. An improperly filled out medical record with incomplete information breeds miscommunication. Provide as much information as you can on the patient's condition and the surgery details. In doing so, you have your patient's best interest in mind and are helping yourself in case a malpractice suit occurs.

Obtain Explicit Written Clearance

When your patient brings their records and documents from specialists, you'll need explicit written clearance. Ensure the evaluating doctor provides a recently written letter explicitly clearing the patient for the surgery. If you lack explicit written clearance, reschedule the surgery until you have valid medical authorization to proceed.

It's also the surgeon's responsibility to ensure that the patient's records are complete and free of errors or inconsistencies. Make sure you review the patient's documents before signing off on the medical clearance. If you notice any discrepancies or potential oversights, don't hesitate to reach out to the evaluating doctor.

Request a Quote From Gallagher Malpractice Today

Navigating the obstacles that a medical malpractice claim presents is especially challenging when you lack a sufficient safety net. Gallagher Malpractice is the largest advisor for medical malpractice in the United States, owing to our innovative approach and the genuine relationships we build with our clients. Safeguard your practice by requesting a quote from Gallagher Malpractice today!