The trusted source for
healthcare information and
These Items Can Prove Important in Lawsuits
Linda M. Stimmel, JD, a partner with the Dallas, TX-based law firm of Stewart Stimmel, says that it is difficult to know with certainty what type of information documented in a chart by an ED nurse or physician may become critical if a lawsuit ensures regarding the care of that patient.
"Many times, something as simple as a check mark as to whether the patient had anything to eat or drink while they were in the ED may become an important fact in the defense of a lawsuit," says Stimmel. Here are some of Stimmel's recommendations:
Consider that a comment made by a family member or the patient may be important to chart.
For instance, a comment such as "I haven't been following up with my medication from my primary care provider," is important to note.
Be specific about what you tell consultants.
Stimmel has defended many hospitals and EDs in lawsuits alleging they did not follow the appropriate chain-of-command process when a physician was needed to consult on the pateint.
"It is very important to document your chart objectively and not subjectively," says Stimmel. "This can be particularly important when defending an allegation of a hospital or ED not invoking the appropriate chain-of-command."
Stimmel says she would advise the ED staff to chart in detail what was told to the consulting physician and not just "I informed the physician of the status of the patient."
If a lawsuit is filed, she explains, it may be two years later. Many times, the consulting physician will testify they were not given the appropriate information by the ED staff.
"If the ED staff had documented exactly the details told to the physician, it would be much easier to defend," says Stimmel.
Put important statements by patients in quotation marks.
Many times, a chart will say that an ED patient is non-compliant, but give no details. "Two to three years later, you do not remember why you charted the patient was non-complaint," says Stimmel. "Be specific in the reasons for the non-compliance. Give an objective description, not a subjective one."
Be sure the history and physical is complete and accurate.
Even though it is impossible to know what small detail may become important in a future lawsuit, Stimmel says that the significant issues in any ED chart would be the history and physical.
"Many times, entries are written hurriedly, and there are mistakes in the history and physical," says Stimmel. "This helps a plaintiff's attorney paint a picture of a staff that was in a hurry and not paying attention."
Additionally, the vital signs should be clear, accurate, and written legibly. "Any consultations and any efforts to reach family also should be well-charted," says Stimmel.