Malpractice Claims: Documentation Lessons Learned Medical - - PowerPoint PPT Presentation

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

END