Failing to Complete a Proper Assessment of a Patient Could Lead to Professional Misconduct
Health professionals should be cautious about offering medical advice or treatment without a proper assessment. Professionally, it is risky to provide care without seeing or evaluating the patient.
Two Canadian cases highlight the consequences of circumventing a proper, in-person assessment. In Saskatchewan, a physician was charged with professional misconduct for prescribing medication and issuing a medical absence certificate to a patient based on third-party information and without assessing the patient. The matter was resolved through alternative dispute resolution with the College of Physicians and Surgeons of Saskatchewan and resulted in the physician being required to complete education and remediation.
In the second case, a physician in Prince Edward Island recorded in a patient chart that he performed physical exams and he billed for the visits. However, an investigation by the College of Physicians and Surgeons of Prince Edward Island revealed that the physician spoke to the patient from the door and did not enter the patient’s room. The College found this to be professional misconduct, resulting in a fine and mandatory education on negligence and liability.
In Ontario, the Schedule of Benefits for Physician Services outlines specific elements of assessments, (and services that include assessments, (such as consultations) that are required when billing OHIP. To bill for a general assessment, the service must include:
A relevant history (including medical, family, and social history)
A physical examination appropriate to the patient’s condition
Billing for an assessment without meeting these criteria may be considered improper billing under the Health Insurance Act and/or professional misconduct.
The College of Physicians and Surgeons of Ontario (CPSO) emphasizes that physicians must document patient interactions in a way that supports the rationale for treatment or procedures. Physicians must keep:
Accurate and complete documentation of the patient’s health status and concerns
A clear record of the assessment and clinical decision-making
Timely documentation, ideally contemporaneous with the encounter
These expectations are outlined in the CPSO’s Medical Records Documentation policy and its companion Advice to the Profession.
Why It Matters
Health professionals should be cautious to offer medical advice or treatment without a proper assessment. Professionally, it is dangerous to offer care without actually seeing and properly assessing patients, and can lead to regulatory consequences such as allegations of professional misconduct or incompetence.
Conducting a proper assessment of patients is foundational to safe, effective care. It ensures that diagnoses are accurate, treatments are appropriate, and patients are truly heard. If patients feel that their health professionals are providing proper care, they will also be encouraged to share more information with their treating professionals, resulting in better care outcomes.
If you have any questions about proper patient assessments or OHIP billing requirements, please don't hesitate to contact us.
