General Surgery: Miscommunication and Inaccurate Documentation (Claims Corner CME)


Failures of systems often prevent physicians from making timely diagnoses. Failures may result when documentation is inconsistent or not thoroughly read. Other factors that hinder timely diagnosis include inadequate hand-offs or referrals. System failures may result when there is a lack of coordination of appropriate care among providers. Coordination between physicians and an adequate understanding of who is responsible for overseeing and ensuring that the patient gets the care needed is critical.

Course ID #: TDE 200740.0 Issue Date: 04/15/2020 Expiration Date: 04/15/2023


After completing this activity, learners will be able to:

  • Include all physicians in the consultation documents
  • Ensuring there is clarity of who is responsible for the coordination of care
  • Reassess my reports, as a pathologist, a second time to ensure accurate diagnosis and following established protocol
  • Conduct an accurate and thorough review, as a surgeon, concerning all relevant documentation and reports of pathology


No individual in a position to control or influence the content of this activity has reported relevant financial relationships with commercial interests. No commercial support was provided for this activity.


The information and guidelines contained in this activity are generalized and may not apply to all practice situations. We recommend that legal advice be obtained from a qualified attorney for specific application to your practice. The information is intended for educational purposes and should be used as a reference guide only.

Course Developers

Susan Shepard, MSN, MA, RN, CPHRM, Senior Director, Patient Safety and Risk Management Education, Department of Patient Safety and Risk Management, The Doctors Company

Kimberly Hathaway, Healthcare Quality and Risk Consultant, Department of Patient Safety and Risk Management, The Doctors Company

Continuing Education Credit

The Doctors Company is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical educational activities for physicians.

The Doctors Company designates this activity for a maximum of 0.5 AMA PRA Category 1 Credit™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Complies with State Requirements

Please SEE the Federation of State Medical Boards overview of Continuing Medical Education requirements by State

Technical Requirements

The activity is best experienced using the most current browser: Firefox, Chrome, Safari, or Microsoft Edge. Internet Explorer is not supported on this platform. All activities featuring audio must have a speaker. To view graphic images and references that appear in separate "pop-up" windows, JavaScript and session cookies must be enabled on your computer. Adobe Acrobat Reader may be required for certain activities.

Contact Us

If you have questions, contact or call 800.421.2368, extension 1243.


Visit our Resource document for this program.