Risk Management Update
By Sue Dill Calloway, RN, MSN, JD, Director of Risk Management, Ohio Hospital Association, Columbus, OH
Q: Last week, I was triaging a patient and I asked her if she was allergic to any medicines and she replied "no." I then entered into the medical record "NKDA," which is our accepted abbreviation for no known drug allergies. When the ED physician examined the patient, he informed her that he was going to prescribe two medications and he noted from the chart that she was not allergic to anything. She now recalls she is allergic to Keflex. How should this be documented?
A: When speaking on legal issues to nurses and physicians, I am often asked what is the best way to keep us out of the courtroom. My answer is that there are two things that can serve as a key to malpractice prevention. These are 1) "good PR" and good communication and 2) good documentation. This scenario brings to play the issue of good documentation. Good concise charting can be the nurse's and physician's best defense in a malpractice suit. Courts have concluded that excellence of the nurse's charting can demonstrate the patient received good care and that it added the court in its search for the facts.1 On the other side of the coin, courts have held that the lack of documentation suggests lack of care.2 Another court held that when there were no notations in the medical record, the jury could conclude that there was no monitoring done.3 One court warned that the availability and accuracy of the medical record is not a mere technicality, but a legal requirement.4
In this scenario, the physician should not obliterate the entry. An optimal practice would be to just draw an arrow to the side and date and time the entry and write, "patient just recalled she is allergic to Keflex" and then initial or sign the entry in accordance with the facility's policy for signing entries. Some emergency departments require documentation that an allergy bracelet has been put on so any facilities with such a policy would want to make sure this was done.
Also, health care practitioners should be aware of any internal policies and procedures for correction or additions to medical records. Failure to follow one's own internal policy and procedure can be discovered by a plaintiff's attorney and used in the courtroom to diminish the credibility of the nurse or physician.
If a patient is less than truthful on the history, again, the importance of documentation can not be over emphasized. Patients have specific rights, but they also have specific responsibilities. One of these responsibilities is to provide truthful information to practitioners in order that a correct diagnosis and treatment can be prescribed. Most states have a comparative negligence or a contributory negligence law in effect.
Even if a practitioner is negligent, there may be no liability if the patient is more negligent than the practitioners. This is why it is so important for nurses and physicians to document clearly when patients do not follow medical advice. It is also important when patients intentionally and knowingly withhold important information. For example, a patient seeks treatment for a laceration. When asked how the injury occurs, the patient states that she cut it washing dishes. In actuality, the patient received a human bite during an altercation. Without this important information, treatment may be different. The practitioner politely confronts the patient and explains that it looks like a bite mark and explains that medical treatment is different. The patient admits it is a human bite. The documentation might read as follows:
14:00: Patient relayed to the triage nurse that the mechanism of injury was that her hand was cut while washing dishes at home approximately a half hour prior to admission. Upon inspection of the wound on her right hand, it appears more like a bite mark. Upon questioning the patient, she admits she was bitten by her husband during an altercation a half hour prior to admission. There is minimal edema and bruising around the wound with two 1.0 cm lacerations that were cleaned with betadine for 20 minutes and left open. (see illustration). The patient was given a wound infection sheet and explained the importance of watching for signs of infection. She was given a prescription for Keflex 500 mg PO to take qid (CK). She was instructed to take it until it is gone. She is to follow up with her family doctor in two days. She was given a Td 0.5mg IM in the right deltoid.
Health care providers should always document incidences in which patients are poor historians or when patients recall important information when they have been previously asked. Good documentation remains one of the most important strategies to keep the nurse and physician out of the courtroom.
1. Engle v. Clark, 346 S.W. 13, (1961, Ct. App. Ky.)
2. Wagner v. Kaiser Foundation Hospital, 589 P. 2s 1106 (1979, Or.)
3. Stack v. Wagner, 368 A.2d 292, (1976, Pa.) 4. Valcin V. Public Health Trust of Dade County, Jackson Hospital, 3rd District, Case No. 91-2131 (1984, Fla.)