Transcript Nursing Documentation - University of Utah

RISK MANAGEMENT OVERVIEW 2014
Louise E. Swensen, JD, MS, CPHRM
Associate Director
 Role
of Risk Management in the Hospital
 When to call Risk Management
 Medical Malpractice & Disclosure
 Informed Consent
 Communication & Documentation
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Review all serious patient events (incident reporting
system)
Patient complaints and grievances – work with
Customer Service
Handle all visits from UDOH, CMS, DOPL, FBI, etc.
EMTALA investigations
Work with Quality to do mandatory State reporting
Review patient legal documents – custody,
guardianship, etc. in conjunction with the OGC
Involved with device & product recalls
Unanticipated, negative
outcomes
 Neurological injury
 Medication errors
 Falls
 Maternal/fetal injury or
death

Implant device
failures
 Patient injury
 Patient or family
threaten to sue
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Is professional negligence by ACT or
OMISSION by a Health Care Provider which
deviates from accepted standards of practice in
the medical community and causes injury to
the patient.
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Is not the absence of a “perfect result.”
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Is not the occurrence of known complications.
Failure to diagnose
 Failure to refer
 Procedure complications
 Failure to obtain informed consent
 Inadequate communication
 Inadequate history and physical
 Patient dissatisfaction with outcome/unrealistic
expectations
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Interns and residents are named in about
30% of the 40-50 Notices of
Intent/Notices of Claim filed against the
University each year.
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The Hospital and
SOM have
established selfinsured trust funds
for malpractice
coverage
Excess coverage is
purchased above the
trust fund amounts
through a
commercial carrier
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Coverage applies
when you are
working within the
course and scope of
your employment at
the University
1. Duty
2. Breach of the Duty (Standard
of Care)
3. Injury (breach is the proximate cause)
4. Damages
1. Take care of the patient
2. Contact Risk Management for help with
disclosing to the patient/family
3. Document thoroughly and carefully including
the physical assessment of the patient.
4.“Privileged” conversations - QI, M&M, RCA
5. Don’t make copies of Patient Safety Net (PSN)
(incident) Reports or refer to them in the
medical record
When asked if anything could have been done to
avert legal action, 37% said an explanation and
apology would have made a difference.
In another study, 24% said they filed when “they
realized the physician had failed to be
completely honest with them about what
happened, allowed them to believe things that
were not true, or intentionally misled them.”
Treatments performed
 Medications ordered & given
 Procedures performed
 Evidence of patient’s overall condition &
response to treatment
 Lapses in care
 Inappropriate care
 Inconsistencies/discrepancies
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 Notice
of Claim/Notice of Intent
 Pre-litigation Panel
 Complaint
 Discovery
 Trial
In Writing
 Nature and Purpose of the proposed Procedure
 Discussion of Risks, Benefits, potential
Complications & Alternatives
 Who will perform the procedure
 Opportunity to ask & have all questions
answered
 Emergency Exception
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The medical record is meant to be:
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A complete, accurate, up-to-date
documentation of the medical history,
condition, and treatment of each patient.
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The primary means of communication for the
healthcare delivery team.
Follow organizational and departmental
policies
 Maintain continuity of care
 As soon after the event as possible
 Timely entries:
◦ Are more believable
◦ Enhance communication and improved
quality of care
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◦Never obliterate, alter, or destroy
original note
◦Never use correction fluid or tape
◦Single line through incorrect entry
◦Sign & date (& time) the change
 Don’t
ever destroy evidence
 Don’t ever change the medical record
 Do label any addition to the medical
record as a ‘correction’ or ‘late entry’ or
‘addendum’
 Do time and date your entries in the
medical record
 Do chart objectively
 Don’t
criticize or question care by others
in the medical record
 Do chart patient non-compliance
 Do chart complications objectively
without assessing fault
 Do chart notification & involvement of
other physicians or other health care
providers
 Don’t editorialize about the patient
 Don’t
use the medical record as a
battleground to settle grudges with other
members of the treatment team.
 The
professionalism of the treatment
team should be reflected throughout the
medical record documentation.
“11/23/83 [pt’s name removed] states that there is
some discomfort over the tip of the ulnar styloid of
her right wrist and she complains of some vague pain
over the dorsum of her right hand. I think she may
just be a chronic complainer. She does not have
exactly the same pain as before but she is just full of
one problem after another and I am unable to
ascertain exactly what her bitch is at this time, but I
think its mostly a vague discomfort so therefore
we’ve removed the cast, placed her in a protective
splint. We’ll start active PT on Monday.”
M.D.
Any questions, any time . . .
Contact Risk Management
581-2031