Oh, the lowly addendum. Most physicians rarely give it a second thought. But, it can sometimes become the single most important part of the dictation. So, why do most of us ignore the addendum? And, yet how can it be one of the most important parts of our report at the same time? Well, that is today’s topic!!! So let’s delve into the legal, medical, and ethical implications of the lowly addendum.
The Lowdown On The Lowly Addendum
OK. I will be the first to admit that the addendum is not the most exciting part of a dictation. Who wants to read that you discussed a case with physician x at time y on floor z? And, who really cares that you had to add a correction to your dictation that seems so minor. But, there is so much more to the addendum. Let me show you below…
Addenda And The Legal World
First and foremost, the addendum is often the only part of the dictation that can protect us from a lawsuit. Many addenda incorporate a time, place, and person after we discuss a case with a clinician. Usually, we place it after the “final dictation”. In fact, sometimes it is the only documentation in the chart that the radiologist actually took the time to give the caring physician the results of a report.
On the other hand, when the addendum is absent in the case of a serious diagnosis and the patient encounters severe morbidity, we leave ourselves open to the legal system. Who is to say that the clinician looked at the results of the report on your patient with appendicitis? It is only the addendum that documents this important information.
When Absence Of An Addendum Is Legally Important
Ironically, the absence of an addendum can also protect the radiologist. If you write addenda on a routine basis every time you discuss a case with a clinician, then when you don’t write an addendum, a communication never occurred.
How is that important? Well, let me give you an example: You have just dictated a normal case on a pediatric chest film with a history of shortness of breath. And, the clinician states that he/she discussed the case with you. On the deposition, he claims that he told you about the possibility of child abuse on this patient and that you told him/her not to order a leg film to look for a fracture. Since the test was not ordered at your hospital, it turns out the patient went to another hospital for additional imaging 3 days later with a positive study for a leg fracture. Perhaps, the fracture did not set correctly. Well, if you did not document the discussion with this clinician, it never happened (unless the other physician can prove otherwise). It is no longer your fault that the clinician did not order the correct test in your hospital!
Addenda And The Medical Record
Addenda can also be important for determining the order of events during a patient stay. At times, a nurse may poorly document the time of events crucial to determining a diagnosis for the patient. Documentation of communication in an addendum can help to clarify when events occurred. Theoretically, it can differentiate if a disease/illness was caused by x or y.
Alternatively, often times we will issue an addendum as a correction to our dictation. Sometimes, we may see a finding we may not have documented in the “final report”. Placing an addendum, in this case, becomes medically important. If a clinician looks back and does not see, for instance, a sclerotic bone lesion in your report, he/she may not know that it exists. The treatment can potentially change, leading to poor patient care. On the other hand, if you issue an addendum and communicate the results, you protect the patient (in addition to yourself!).
Or maybe, you made a typo in the history and said the patient had a history of breast cancer versus the real history of prostate cancer. Believe it or not, this can have significant implications for insurance companies reimbursing a patient for the imaging study. A wrong history can lead to a denial of care payment for a patient. An addendum as a correction can be a life saver for this patient. It is very frustrating to have to deal with denial of care payment issues when you are sick!!!
Ethical Obligations To The Addendum
In order to abide by our Hippocratic oath, we as physicians are ethically obliged to do the best for our patients and do no harm. Based upon some of the examples above, by creating addenda we fulfill a moral and ethical imperative to improve patient care. So even though mostly overlooked by many readers, we need to be vigilant about reporting addenda when necessary. Don’t forget about the lowly addendum!!!