Malpractice Claims: Documentation Lessons Learned
Medical Malpractice • Recurring Core Issues: DOCUMENTATION • Lessons Learned Through Real Cases: 1. Proofread your notes/dictation 2. Know your EMR 3. Be careful in how you “say it” 4. Documentation can win the day
Case 1: Proofread Notes/Dictation • 60 yr old to undergo carotid endarterectomy • No significant hx of coronary artery disease • Surgical procedure successful, no apparent complications • Massive myocardial infarction 24hrs after discharge
Case 1 Cont. Plaintiff Contended: 1. Should have performed more testing for clearance 2. Further testing would have revealed significant CAD 3. If significant CAD was known, no surgery, no MI Defense Contended: 1. Met standard of care 2. Rigorous clearance testing not indicated because no significant hx of CAD
Case 1 Cont. • Problem: Documentation/transcription error in pre-op H&P contradicted the defense theory • Lesson Learned: PROOFREAD
Case 2: Know Your EMR • 60 year old male with history of elevated PSA/prostatic biopsy 10 years ago • February, 2008 – to urologist with elevation in PSA. Schedule repeat biopsy • Standard Protocol – Prophylactic ABX • Standard of Care • Prostate Biopsy • Patient did not receive ABX • Becomes septic and is hospitalized for 3+ weeks
Case 2 Cont. • Plaintiff Contended: Defendant negligently failed to give prophylactic ABx prior to biopsy, resulting in sepsis • Defendant Contended: Plaintiff reported taking prophylactic ABx prior to procedure • Issue: • Plaintiff denied telling physician that he/she took ABx • Defendant did not recall independently, but documented that pt reported taking ABx • Defense depended on credibility of chart Problem: Auto populate
Case 2 Cont.
Case 2 Cont.
Case 2 Cont.
Case 2 Cont.
Case 2 Cont. • Lessons Learned: 1. Know your EMR and how it works 2. Be aware of auto populate features 3. Enter as much information as possible yourself
Case 3: Be Careful How You “Say It” • Defendant internal medicine doctor sees 59 yr old pt in office on Friday – CXR possible rt. Middle lobe pneumonia. Prescribed appropriate ABx and sent home • Progressed to ARDs over weekend • Admitted Monday A.M. • 1 week later transferred to large hospital • Died 3 weeks later
Case 3 Cont. • Plaintiff Contended: • Defendant Contended: • appropriate dx and tx regimen • Voluntarily dismissed before trial, but after years of litigation
Case 3 Cont. • Why was the case even filed? • Residents H & P: “inadequately treated community acquired pneumonia ” • Resident intended to convey that infection had not yet responded to the medication • Lesson Learned: BE CAREFUL HOW YOU SAY IT
Case 4: Documentation Can Win the Day • 39 yr old male presents to ER with history of syncopal episode and no active chest pain—but had chest pain the previous day • ER doctor evaluates pt • EKG shows LBBB • Normal cardiac enzymes
Case 4 Cont. • ER doctor speaks with PCP, who admits pt to be monitored with serial enzymes and continuous telemetry • PCP sees pt at 8:45 P.M. • Repeat EKG shows no changes • No chest pain or SOB • Cardiac enzymes not elevated
Case 4 Cont. • Pt wanted to go home • PCP kept pt overnight • Called cardiologist at larger hospital • Explained presentation, tx, and asked for input • Cardiologist concurred with tx plan and indicated no need to transfer pt that night to cardiologist service • Cardiologist said fine transfer next day or to f/u outpatient • Pt suffered fatal arrhythmia at approx. 11P.M.
Case 4 Cont. • Plaintiff Contended: Defendant PCP negligently failed to transfer pt to cardiology that evening
Case 4 Cont. • Defendant contended he did consider transferring pt that evening and made proper decision not to do so • Defendant’s progress note • Proof jury needed was in the note—Defense verdict • Lesson Learned: Documentation can win the day
Best Way to Protect Yourself • Insurance • Understand your limits • Individual limits? • Shared limits? • Tail Coverage • New practice v. Former practice
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