Risk Management Articles

Keeping Abreast of The Masses: Tools To Improve Documentation Of Breast Exams
By: Harvey E. Knoernschild, M.D., FACS

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Over the past four years, the medical liability industry has experienced a 70% increase in the incidence of "failure to diagnose" breast cancer cases. Likewise, CAP/MPT has monitored the frequency of these types of claims and remains concerned about the apparent upward trend. As a result, CAP's Board of Trustees and Directors have approved a membership program designed to help reduce the number of these claims. A review of these delayed diagnosis claims has revealed two major problem areas:

• Inadequate documentation of abnormal breast findings in patient records, and
  
• Delayed referral of patients with breast masses to an appropriate specialist.
  
  

These two problems are interrelated. Without thorough and accurate documentation of breast exam findings, changes in the size and consistency of breast masses may go unnoticed. A physician's fallible memory is an unreliable source of comparative details (e.g., the precise location, size, shape and texture of a breast mass) when examining a patient three or six months later. Drawing two "fried eggs" on the patient's record, with an ill-defined blob to indicate the presence of a breast mass, provides no useful comparative data. Failure to properly document breast mass findings is equivalent to neglecting to record accurate blood pressures when treating hypertension. Both practices will increase the likelihood of errors in treatment and delays in diagnosis.

CAP/MPT hopes to decrease the incidence of delayed diagnosis of breast cancer by improving the documentation of breast exam findings.

To assist and encourage our members to record their findings of breast masses, a "Breast Mass Documentation Kit" will be sent to all primary care physicians, OB-GYNs, and general surgeons. Included in this free kit will be a self-inking "breast stamp" for recording breast findings, a suggested "texture key," and a suggested management algorithm based on current information from the medical literature. Any other CAP/MPT physician who regularly examines breasts may request a free kit.

CAP/MPT encourages its members to use these materials to record abnormal findings during breast examinations. Every member benefits through lower insurance costs if the tools in this Breast Mass Documentation Kit help to reduce the number and severity of these types of claims. Please encourage your CAP/MPT colleagues to use the Breast Mass Documentation Kit when a breast exam yields abnormal findings.


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