Incidental Findings Can Arise in Every Practice

Incidental findings are defined as any findings that are discovered during medical treatment/evaluation that could potentially affect the health of a patient when the diagnostic treatment/evaluation actions were not intended to yield such findings.

A question which arises frequently is whether you, the provider, who is treating the patient for a specific service or treatment has a duty to advise the patient of other health issues (aka incidental findings) you may note as you provide the specific service for which you are seeing the patient.

The answer is a resounding “yes.” 

Although you may only be seeing the patient for a specific procedure or service, you are initiating a “doctor/patient” relationship. As such, you owe a duty of beneficence to the patient, meaning a duty to promote the patient’s welfare and do no harm.

If you recognize a situation which you reasonably believe may be adverse to the patient’s health and may or may not require immediate attention but, if not acted upon, may worsen over time and possibly result in an adverse patient outcome, you should advise the patient and document your records accordingly. 

A couple of additional steps you should take in addition to advising the patient of the incidental finding:

  • Document the fact the patient is presenting only for a specific treatment or service and therefore a complete and thorough exam may not be completed. 
  • Include language in the informed consent discussion, the informed consent form and any written information you provide that the treatment is limited to the providing of the specific service or treatment and referrals may be necessary if additional treatment or evaluation is necessary.

However, again, if an incidental finding is revealed during the treatment, you should address the issue with the patient and/or refer the patient accordingly.

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