Transcript Mitigating Medical Malpractice Risks Through Documentation

Mitigating Medical Malpractice Risks
Through Documentation
Atty Work Product: Confidential
Presented by: Chamiza Pacheco de Alas, Esq.
Associate University Counsel
UNMHSC Office of the University Counsel
Med Mal Claims and Lawsuits Process
Overview at UNM Health System
 Tort Claim Notice Received within 90 days of alleged injury
 Litigation Hold Email goes out requesting preservation and
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production of documents NOT in medical record. This is a
legal evidentiary requirement, does not mean you are being
named/sued/targeted, etc.
Certification and documents returned within two weeks.
“Key providers” (people we think have best/most information)
interviewed.
Decision made to recommend settle, deny or “sit on it” to
State RMD, hopefully within 90 days.
Subsequent lawsuit may be filed within 2 years of incident (for
adults)
Communication Best Practices
 Need an effective way for patients/family members to reach
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team (and eventually attending) at any time.
Need a specific time frame established for seeing patients
who are new admitted, critically ill, or experiencing
significant changes.
Sit at eye level with patients when communicating.
Use active listening.
Ask patients to repeat back what you have said.
Treat patients concerns seriously.
Encourage family involvement.
Best Practices for Consultations
 Try to avoid curbside consultations that go beyond questions
aimed at the general education of the requesting physician.
(i.e.no questions about: specific tests or studies, record
review would be best practice, diagnosis confirmation is
requested).
 Document when a consult is requested in the record, and
when it is received (if possible). Important to get accurate
timelines in the record. If consult is refused, document that
and the stated reasons. Consultants should be doing parallel
documentation.
Best Practices For Documentation
 Medical Records tells the story of the patient’s care and should do so accurately and
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meaningfully.
DO NOT cut and paste (particularly from medical student notes, usually by residents)—
it is very obvious. Check notes before you co-sign for cutting and pasting. Be
particularly mindful in cases with conflict or difficult social situations.
If you disagree with something a medical student or resident has stated relating to
patient care, document in an addenda or new note.
Note times where relevant .
Use a neutral tone in documentation, particularly where there are conflicts between
services—just the facts.
Medical record is not confidential or privileged, do not put things that should be
confidential and privileged, such as advice from Office of the University Counsel, in the
medical record.
Be careful about how you document advice received from non clinical entities (i.e. risk
management)—at times that advice is misstated putting the institution in a bad situation.
Mock case: What should be in the note and
how (from a medical-legal perspective)?
Mary Lamb, 72, came into the E.D. at 1AM complaining of
chest pain, shortness of breath, and trouble sleeping. She stated
she spent the day chasing sheep. The E.D. paged Dr. Smith, a
resident, at 4AM asking for a consult regarding admission. Dr.
Smith saw the patient at 6AM. Cardiology had been consulted
by the E.D. but had not yet seen the patient when the resident
saw him. Mary Lamb has a history of falls and reports she has
been told she has some sort of “blood clot problem”. She
doesn’t believe it. She reports taking a variety of homeopathic
medications but can’t remember them all. She is requesting to
go home because she is tired of waiting and the gurney in the
E.D. is uncomfortable.
Mock Case: Documenting Social Issues
 Miles McQueen is a 19 year old developmentally disabled man being cared for by his
parents, who are divorced. There is no documented power of attorney. There has been no
formal assessment of his capacity. He has been admitted to your service due to his
uncontrolled diabetes.You have instructed both parents that he must be on a very strict
diet and insulin management regime. Nursing reports to you that his mother was seen
feeding him ho hos at lunch, and then giving him insulin she brought from home. When
confronted by nursing she stated that the insulin “fixed the sugar from the ho hos”. When
you spoke to her and told her she had to stop feeding him food from home and
dispensing insulin she stated “he’s my kid, I get to decide what happens to him in here.”
You become concerned and call legal, you are advised to formally evaluate capacity and
to consider an APS referral. You page psychiatry and are told they cannot do a capacity
evaluation without knowing “what the decision is they are evaluating his capacity in
reference to.” Later that night, you receive a report from nursing that the mother was
feeding her son an in ice cream sundae and when confronted by nursing staff replied
“f*&k off, he’s my kid, I’ll do whatever I want. I’m taking him home in the morning”
Nursing stated they and her son were both fearful. Additionally, they smelled alcohol on
her breath. The next morning, you call Adult Protective Services. They state they won’t
be investigating as he is in a safe place. What do you document? How?
Example of good social documentation
 ID: 3 wk PHM presented with acute L humerus fx, admitted
for NAT. Currently on medical hold.
 24 hr events:
 Pt remained clinically stable overnight
 Pediatrics, CART and CYFD had prolonged discussion with
multiple CYFD officers regarding their original assessment of
returning patient to parents under supervision of a safety
monitor. CYFD persisted in adhering to their initial plan.
Pediatrics placed medical hold on patient. APD contacted.
CYFD revised discharged plan and required the father to leave
the home premises prior to pt returning home. Father cannot
be alone with pt. without supervision.
Discussion/Questions?