If you know how to document then you know how to defend yourself in court and against the board. Learning how to document is not something that is well taught in school, orientation, and many times by preceptors or within organizations. Let’s review a few cases in which documentation was at the center of the litigation.
In Susan Meek. V. Southern Baptist Hospital of Florida, Inc. d/b/a Baptist Medical Center, the patient (plaintiff) was admitted to the hospital for a hysterectomy. She developed bleeding after surgery and was admitted to the radiology unit for uterine artery embolization (UAE) to stop the bleeding. Although the physician ordered the nurses to perform frequent leg examinations to mitigate the risk of diminished blood flow and nerve injury (a known complication of UAE), the patient claimed the exams were not performed, based on lack of documentation. The patient sustained nerve damage after a massive clot was removed in the external iliac artery. The case resulted in a $1.5 million verdict. The nurses were unable to defend the care that they provided because they did not have any supporting documentation.
In another case, Battocchi v. Washington Hospital Center, 581 A.2d 759 (D.C. App. 1990), the plaintiff sued the hospital for medical malpractice related to an injury that occurred when a provider used forceps on their child during the delivery. The nurse documented the events and her observations appropriately, but Risk Management lost a copy of her notes before the trial began. The lower court ruled for the hospital and would not allow the jury to infer causation or negligence even though the hospital lost the nurse’s notes. On Appeal the court remanded the case back to the trial court to decide on whether the hospital’s loss of he records resulted in negligence or impropriety. Is it fair to the family to lose the case based on the hospital’s negligence?
There are the types of documentation issues that cause conflicts and lead to litigation. How can you as a clinician or provider protect yourself? You have to know what to document, how to document, and how to use your documentation to avoid litigation.
So, I created Documentation to Avoid Litigation to give healthcare providers a direct view inside the world of an attorney who has consulted on medical malpractice cases and seen some of the best and some of the worse instances of documentation. More importantly, it is a blueprint on how to become efficient and effective at documenting to protect your patient and your practice.
Do you really know how to document? If you are not quite sure, then sign up for my course today.
I am a healthcare lawyer and I work with businesses that have healthcare practices in Maryland. I consult with clients across the nation to provide healthcare consulting, compliance, and training on HIPAA, Intake, and Workflows, as well as Documentation and other legal topics.
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