Articles Tagged With: Documentation
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EMS Documentation Can Complicate Defense of ED Claim
Unpacking the various reasons why emergency medical service providers could become involved in emergency department malpractice lawsuits.
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Lawsuits Allege Negligent ED Care Caused Hospitalized Patient’s Poor Outcome
When emergency department patients are admitted but not yet transferred, that is a point of weakness for facilities.
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Wrong Box Checked in Chart? Common, Careless Error Complicates Defense
There are two types of discrepancies that can cause major problems for the defense during malpractice litigation. One, a discrepancy between the emergency physician's (EP) documentation and nursing documentation. Two, a discrepancy between the EP and obvious reality.
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Surgery Centers Can Improve Patient Record Documentation
From a nursing perspective, medical recordkeeping is more about risk management than it is about complying with regulations. All medical records from surgery centers should tell the stories of patients and include details about their episodes of care.
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Ethics Recommendations Span Years for Some Patients
When someone requests an ethics consult, the patient’s social and clinical history is important to know. So is the history of ethicists’ involvement. It is not uncommon for a consult service to be called multiple times over several to assist with a care question that resurfaces.
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Payers, Hospitals Disagree About Whether Patient Meets Inpatient Criteria
Payers are refusing to pay claims for gastric bypass, joint replacement, and even cataract extraction. Why? Because documentation in the record does not support the need for surgery.
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Missing Clinical Documentation Reason for Many Claims Denials
More health plans are asking for certain pieces of clinical documentation before paying claims. If it is not there, the claim is denied. What are the specific issues arising?
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Defensive Charting Can Lead to Unintended Consequences for Everyone
If EPs do not see the nursing notes, they will not be able to address statements claiming they did nothing to address a patient’s deteriorating condition.
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Consults, Studies Recommended By Others Carry Med/Mal Implications for EPs
Somewhere in the ED chart, somebody recommends involvement of a particular specialist, or that a specific study should be conducted. When this kind of recommendation is documented but never acted on, it can mean legal trouble for the EP.
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The Capacity Conundrum in Emergency Medicine
A patient’s capacity to give informed consent or to leave the emergency department against medical advice is a topic of great relevance to emergency clinicians. This article discusses the difference between competence and capacity and highlights the four essential elements involved in the assessment of a patient’s capacity.