Articles Tagged With: Documentation
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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.
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Template Charting on Nursing Notes Complicates Med/Mal Defense
Instead of making blanket statements about review of nursing notes, the emergency physician should document accurately. If the physician did not actually review the nursing notes, stay silent on it.
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Do Not Promise Success, and Document Well
There are two things healthcare professionals can do to position themselves for a good defense in case of a malpractice lawsuit. First, do not promise patients success or even imply it. Also, be careful when creating policies and procedures.