Sample disclosure note to put in patient record

This is an example of how Fay Rozovsky, JD, MPH, president of the Rozovsky Group, a risk management firm in Bloomfield, CT, suggests a disclosure conversation should be documented:

1930 hours Nov. 12, 2005. I met with Ms. Tsumanez and her partner, Mr. Rouez, to discuss the unanticipated outcome experienced yesterday. In attendance with me was Nurse Della Stuart, the nurse manager for the post-surgery unit. Since Ms. Tsumanez and Mr. Rouez exhibited limited English proficiency, I suggested and they agreed to the use of the 24-hour language line service. Gretchen Colonne served as the interpreter utilizing a Mexican Spanish dialect. Permission for Mr. Rouez to participate in the discussion had been obtained earlier.

I told them that Ms. Tsumanez had received the wrong meal tray three times during the last 24 hours. The meals she received were inappropriate for someone with renal failure. I told them that while it is not certain that this was the cause of the flare-up in her condition, it certainly would not be helpful for someone in her state to receive these foods. I expressed my apology and told them that steps were being taken to find out why the wrong meals had been provided the previous day. I asked if they needed anything. They said no. I asked if they had any questions. Mr. Rouez asked if there would be any permanent damage from what had occurred with the meals. I replied that it was doubtful that there would be any long-term difficulties, especially since the problem had been identified and steps had been taken to assist Ms. Tsumanez with medication. I also pointed out — and Nurse Colonne agreed — that the care plan had been modified to monitor Ms. Tsumanez for any possible side effects. I explained that she should feel better within the next 24 hours. Ms. Tsumanez asked how this could happen, especially since she said she had questioned getting the meals she had received at noon and in the evening. Nurse Colonne asked if Ms. Tsumanez could tell her to whom she had addressed her question. Ms. Tsumanez said she could not remember, but it was not a nurse. To respond to Ms. Tsumanez's question, I replied that the hospital was looking into the process that led to her receiving the wrong meals. She asked if we would let her know the outcome, and I agreed to do so.

— T.J. Shift, MD

(Editor's note: This information is copyrighted by The American Society for Healthcare Risk Management in Chicago and used by permission.)