Articles Tagged With: Documentation
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When ED Providers Overlook Information Conveyed by EMS
The emergency physician and ED nurse should take the report together when EMS arrives. Listen to what EMS found at the scene, what they did in terms of treatment, and what the response to that treatment was. Together, decide on the next steps.
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Family Violence Implicated in Injury-Related ED Visits
ED-based efforts to screen and intervene can be critical to preventing future violence. This is important not only for family and peer violence, but also for contributory factors — mainly, access to alcohol, drugs, and weapons. In addition to obtaining thorough patient and family interviews, using standardized instruments to screen for these factors can help identify youth at risk, and link them to appropriate interventions and care.
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Artificial Intelligence Documentation Assistant Shows Promise for Healthcare Charting
Advocates are seeking relief for physicians overburdened with too many administrative tasks.
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Legal Exposure Regarding Recurrent Low-Risk Chest Pain
The most important actions an emergency physician can take are to gather a thorough medical history and correctly interpret the ECG.
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Chaplains Play Unique Role in Advance Care Planning
Ninety percent of 585 of board-certified healthcare chaplains said advance care planning is important to their work, 70% regularly help patients complete paperwork after discussions, 90% facilitate discussions with patients about their preferences, and 45% reported they were not consistently included in team discussions on decision-making. -
ED Nurses Feel Unprepared for Mental Health Complaints
Engaging with the patient can help ED nurses avoid these risky situations. Nurses can notice subtle signs of escalation, treat with medications when appropriate, offer food, perform regular assessments, and facilitate hygiene. It also is important for ED nurses to demonstrate they did everything in their power to transfer the patient to a higher level of care, if that is what the patient needs. -
Neurology Consult Delays Can Become Issue in Claims
If a stroke patient alleges failure to administer tissue plasminogen activator, whether a timely neurology consult was obtained likely will be a central issue in the litigation. Here are some issues that can arise during litigation. -
Claims Involving Physician Assistant Care Continue
Malpractice claims involving physician assistants in the ED have increased in recent years and are continuing to come up, according to interviews with legal experts. Most emergency physicians who voice concerns are worried about finding themselves defendants in lawsuits — when they never saw or even knew about the patient. -
Problems When Calling Patient a ‘Drug Seeker’
Is this drug-seeking label truly needed to complete the chart? What message are you trying to convey, and to whom? Who is going to read that chart once you close it, and why?
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Checkbox Charting Is Problem for ED Malpractice Defense
Make sure the ED uses modified templates to allow clinicians to add free-form text. Carefully review the record for accuracy before signing the note (including automatically populated checkboxes), either contemporaneously or close in time to the encounter. Finally, maintain a strong compliance program with regular medical record audits, including a review of electronic health record systems.