Documentation: Avoiding the Pitfalls

Summary

This talk delves into the critical role of medical documentation in litigation, highlighting how it can influence legal outcomes. It discusses why patients seek plaintiff attorneys following adverse medical events, emphasizing the importance of clear communication and timely treatment. The speaker addresses common issues like miscommunication, delayed treatment, and the significance of legible orders, using case studies to underscore the consequences of poor documentation. The presentation also touches on the impact of computer order entry errors and the legal implications of record tampering, concluding with the value of educating healthcare staff on documentation to mitigate future litigation risks.

Takeaways

• 📚 Documentation is crucial in litigation as it provides the record of medical decisions and patient care.
• 🤔 Patients often seek plaintiff attorneys to understand the cause of adverse medical outcomes and to get answers.
• 🚑 Miscommunication and delay in treatment are significant factors that can lead to medical errors and subsequent litigation.
• 👩‍⚕️ Healthcare providers sometimes avoid clarifying orders due to fear of negative responses, which can contribute to errors.
• 💊 Errors in medication orders, such as incorrect dosages, can have severe consequences and are a common issue in medical litigation.
• 🏥 Clear and legible orders, as well as accurate documentation, are essential to prevent misunderstandings and protect healthcare providers.
• 💼 Plaintiff attorneys play a role in uncovering what happened in cases where there are bad medical outcomes, often through documentation review.
• 📉 Instances of underreporting incidents due to fear of repercussions can lead to cover-ups and affect the quality of care.
• 📝 Tampering with records, such as rewriting nursing notes, is unethical and can have legal consequences.
• 🛑 The importance of following a chain of command and understanding one's role and responsibilities in documentation was emphasized.
• 🏢 Education on the impact of documentation on potential litigation can help healthcare staff protect themselves and the institution.

Q & A

What is the primary reason patients seek out plaintiff attorneys after a bad medical outcome?

Patients seek out plaintiff attorneys because they want to know what happened and believe that having someone review their medical records will provide answers.

What was the critical issue in the case where the patient had a Demerol overdose?

The critical issue was the lack of documentation regarding the patient's intolerance to opiates and the resident's decision to ignore the nurse and family's advice, leading to a toxic level of Demerol in the patient's blood.

What was the outcome of the case involving the infant who received an incorrect dosage of cisplatin?

The infant died two days after receiving the incorrect dosage of cisplatin due to a transcription error, and the autopsy revealed toxic levels of the drug in the child's blood.

Why were the nurses reluctant to communicate their concerns to the obstetrician in the North Carolina case?

The nurses were reluctant to communicate their concerns because the obstetrician typically had a negative response when approached about patient issues.

What was the financial settlement in the case where the nurses did not communicate their concerns about fetal monitoring?

The financial settlement in that case was 1.2 million dollars.

What did the study by the Institute for Safe Medication Practices reveal about healthcare providers' communication regarding medication orders?

The study revealed that a majority of healthcare providers had not clarified medication orders due to intimidation, indicating a pervasive problem of miscommunication.

What was the issue with the Hoyer lifts that led to several cases of patients falling and getting injured?

Nursing assistants were afraid to report incidents of patients falling from Hoyer lifts, leading to underreported injuries such as fractured hips or subdural hematomas.

Why was the nursing home note about leaving room for documenting a fall considered tampering with records?

The note suggested a premeditated plan to alter records, which is considered tampering because it implies a deliberate attempt to change documentation after the fact.

How did the hospital staff benefit from Pat's presentation on documentation and its impact on potential litigation?

The hospital staff gained insights into how proper documentation can protect healthcare providers and the hospital, raising awareness about their role and responsibilities in maintaining accurate records.

What was the attendance like for Pat's presentation on documentation, and what does it suggest about the staff's interest?

There were 108 people in attendance across two sessions, suggesting a high level of interest and hunger for understanding the importance of accurate documentation among the hospital staff.