The looming threat of medical malpractice litigation is the fear factor for the modern healthcare provider.
Although there are a lucky few who may go their whole careers without being sued, chances are that at some point you will be involved in litigation, whether as a fact witness or a party defendant. A lawsuit can jeopardize both a healthcare provider’s reputation and self-confidence.
The most important piece of evidence in a medical malpractice suit is the medical chart.
In most jurisdictions, the plaintiff has years to file a lawsuit. As time passes, memories fade and witnesses disappear. What is left is the medical chart telling the story of what occurred. As a busy healthcare practitioner, you may have treated hundreds of patients in the interim, and there is little chance that you will recall the details of every case.
Simply put, you can’t expect to rely upon memory. Rather, you need to make sure the documentation accurately and completely reflects the patient’s condition and the care and treatment that you provided. Your medical notes become part of a permanent and retrievable health record that may someday be scrutinized by your employer, attorneys, risk management, and state surveyors.
While you may be eager to punch out at the end of a long shift, the extra time you spend memorializing the care you provided will pay off in the long run.
How To Ensure Accuracy In Your Documentation
Whether in the form of handwritten notes or electronic documentation, practitioners should strive for documentation that is accurate, complete, timely, and legible.
One of the most common documentation deficiencies is the lack of significant details of the care. This can lead to allegations that care was not being provided—the notorious “not documented, not done.” Your notes must include any assessments, interventions, treatments, or events that occurred, notably any significant indicators of a change in the patient’s status, any subsequent interventions, and the patient’s response.
Take, for instance, a situation where a patient was admitted to a facility with a deep tissue injury, which evolved to a Stage III ulcer over a several-week admission. If no wound assessments were documented, a savvy plaintiff attorney may raise allegations of negligence, claiming that the dressing was never changed and that the nursing staff failed to provide any wound care.
All patient complaints, as well as what action was taken to address the complaint, should be documented. It’s essential to report significant patient complaints to the physician and to document that this was done in order to protect yourself.
For example, when you document that you reported to a physician about a patient’s condition, document everything you told the physician in your note. In some malpractice cases, this becomes an issue when a physician alleges that a nurse didn’t report all the information about the patient’s condition. Your contemporaneous documentation will bolster your testimony in a “he said, she said” case. For the same reason, it’s important to document any notifications and education that you provided to the patient and their family.
Try to avoid finger pointing in the medical chart. Where a care issue exists, it’s important to follow procedure to report staff issues up the chain of command.
Ensure that your punctuation is accurate, as something as simple as a missing comma can alter the whole meaning of the note.
Only document the treatment or procedures immediately after they have been carried out. Never pre-chart or allow certified nursing assistants to pre-chart for the shift. What if the patient is transferred emergently to the hospital for evaluation, or worse, dies? This would certainly lead to a lengthy deposition at best and call into question the rest of your documentation and your credibility as a witness.
For handwritten notes, make sure your documentation is legible and can be understood by other providers. Also, take care to write legibly in flowsheets and graphic notes.
In an electronic chart, be aware that the appropriate check boxes are marked when documenting care, and beware of auto-filling notes with out-of-date, inaccurate information.
Documenting Turning And Repositioning Wound Care Patients
In wound care cases, turning and repositioning of the patient is always an issue. Be consistent in your documentation of when turning and repositioning was performed. If this appears in one note and not another, a plaintiff’s attorney will argue that it was not done. Some facilities have taken to care planning for “frequent” turning and repositioning, or a general requirement for hourly rounding to assess a patient’s individual needs, as there is nothing magical about the 2-hour mark. Indeed, every patient’s condition and requirements may be different.
Be sure to document if a patient refused to be turned and repositioned, using exact quotes if possible. Your notes will be pivotal in the event of a lawsuit. It’s possible that the patient was unaware of the risk of skin breakdown, was in pain, or simply did not want to be moved. Also note what actions you took as a result of the refusal and any education that you provided about the need for repositioning, as well as the patient’s reaction to the education.
No one likes being sued, but in the unfortunate event that you are served with a medical malpractice lawsuit, do not despair. Strong documentation is your best defense.
Laura A. Tull is an attorney at law at Marks, O'Neill, O'Brien, Doherty & Kelly, P.C. in Cherry Hill, NJ.