The urgent call from the labour ward with the news that the infant’s buttocks are on view in what was an expected cephalic presentation, is usually very stressful for obstetricians and patients alike.
Keen to avoid missing a breech presentation at term and to reassure the mother, many obstetricians use their bedside ultrasound machine to check the presenting part and image cardiac activity and foetal movements and demonstrate a glimpse of the face. Expectant mothers and their partners often enjoy this and find it reassuring.
Unfortunately, the possibility of a bedside ultrasound examination being labelled in hindsight as a diagnostic examination, has become a reality.
Allegations of missed complications
In a scenario*, an obstetrician faced a claim where the patient alleged an ultrasound examination missed growth retardation and oligohydramnios. Expert opinion obtained by the patient interpreted an entry in the medical record of “U/S- ceph, FM noted,” as a diagnostic examination. The expert dissected the entry in terms of the requirements of a third trimester ultrasound examination as listed in the Australasian Society for Ultrasound in Medicine Guidelines for the Performance of Third Trimester Ultrasound. The obstetrician had not charged for an ultrasound examination.
Ultrasound examination purpose
This scenario raises several medico-legal issues for obstetricians. The first is discussing with the patient the purpose of an ultrasound examination in order to manage their expectations and clearly documenting the purpose of the examination and the discussion in the medical record.
If the patient had been advised the ultrasound machine was being used purely to check the presentation and foetal heart (rather than seeking to diagnose any abnormalities), it is less likely the allegation would have been made. Documenting, for example, “FH √ ceph √ (U/S)” in the medical records would also have established the purpose of the ultrasound, and limits of the examination.
Charging as a separate service
The second issue concerns charging the ultrasound examination to the patient as a separate service. Charging for ultrasound examinations as a separate service should be done in accordance with the Medicare Benefits Schedule (MBS) descriptor for the service. This will assume the purpose of the examination as a diagnostic ultrasound and will entitle the patient to expect an examination performed in accordance with the guidelines.
The clinical benefits of using bedside ultrasound examinations in the delivery of routine ante-natal care are clear, but the take-home message is to establish appropriate patient expectations and make careful entries in the medical record.
- Advise patients of the purpose of the ultrasound examination to establish appropriate expectations.
- Document the purpose of the ultrasound examination in the patient’s medical record.
- If charging an ultrasound examination as a separate service, this should be done in accordance with the MBS descriptor and explanatory note for the service.
*The scenario in this article is based on some similar cases.
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